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Full text of "Process and outcome efficacy of Internet counseling"

PROCESS AND OUTCOME EFFICACY OF INTERNET COUNSELING 



By 
MARTHA LANA BOGARDUS GROBLE 



A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL 

OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT 

OF THE REQUIREMENTS FOR THE DEGREE OF 

DOCTOR OF PHILOSOPHY 

UNIVERSITY OF FLORIDA 

2002 



Copyright 2002 

By 
Martha Lana Bogardus Groble 



DEDICATION 



This study is dedicated to the memory of 



George A. Bogardus 
1920-2001 

Martha Lucille Clark Bogardus 
1920-1975 

Potato and beef farmers who recited epic poetry at our dinner table, 

insisted that we attend school even when the crops needed harvested, 

instilled a profound love of learning in their children and 

kept the house filled with books. 



ACKNOWLEDGMENTS 

I wish to express my gratitude to my doctoral committee, James Archer, Jr., Harry 
Daniels, David Miller and Linda Shaw who permitted me to develop research in a 
fast-growing and little-researched aspect of counseling. Doug Johnson, the WebCT 
system administrator was an invaluable resource, problem solver, and unexpected source 
of encouragement. James Watson and Alan Pappas provided access and administrative 
support at Santa Fe Community College. 

Robert E. Groble M.D. provided the financial backing for this project and granted 
me leave from office duties to complete it. Kristopher Groble, Loren Groble, and Samuel 
McFadden interfaced with the facilitators to make their work easier. They ran errands, 
and provided data entry, proofreading, and other computer, management, and clerical 
services. 

I want to thank the graduate students who facilitated this experiment. Without 
them, I could not have completed project of this magnitude. Daniel Pekich, rehabilitation 
counseling, and Heather McWilliams, mental health counseling each worked with a large 
number of participants and headed the team of facilitators at the University of Florida and 
Santa Fe Community College respectively. Lakisha Scott, rehabilitation and mental 
health counseling; Lamandra Jenkins, school counseling; Anjanette Todd, school 
counseling; Wendy Marsh, rehabilitation counseling; Angela Falcone, mental health 
counseling; and Lesley LeBaron, marriage and family counseling were seriously 
committed to the students they facilitated and were dedicated to working with a protocol 
and theory that might not have matched their own preference. They brought a broad 



IV 






range of counselor training, personal interest, and racial diversity to the performance of 
this research. 

I appreciate the instructors who permitted me to use precious class time to recruit 
participants and who, in most cases, supported my effort by providing the added 
incentive of extra credit to their students - Laura McCarthy, Dawn Snipes, Michelle 
Murphy, Kitty Fallon, Natalie Arce, Kim Fugate, David Marshall, Keith Carodine, Alan 
Pappas, Michael Smith, Joyce Orr, and Paul Stern. I would be remiss if I did not 
acknowledge all of the participants who shared issues that were sincere and intimate to 
them with their facilitators so that we could learn more about the counseling process and 
outcome in cyberspace. 



TABLE OF CONTENTS 

Page 
DEDICATION iii 

ACKNOWLEDGMENTS iv 

ABSTRACT x 

CHAPTER 

1 INTRODUCTION 1 

Scope of the Problem 7 

Theoretical Framework 9 

Statement of the Problem 14 

Purpose of the Study 15 

Need for the Study 15 

Rationale for the Study 16 

Research Questions 17 

Definition of Terms 17 

Counseling terms 17 

Computer Terms 18 

Organization of the Study 20 

2 REVIEW OF LITERATURE 21 

Internet Counseling Basic Constructs 21 

Social Presence 22 

Mutual trust or trustworthiness 28 

Internet Counseling Issues 29 

Website Security 29 

Legal Considerations 34 

Modalities 35 

Telehealth/Telemedicine 35 

E-mail 35 

Chat/Conferencing 36 

Multi-modal 39 

Unidirectional Information Only 40 

Guidelines for Ethical Practice of Internet Counseling 40 



VI 



Credential Validating Referral Sites 41 

Advantages of Internet Counseling 45 

Disadvantages of Internet Counseling 46 

Cognitive Behavioral Counseling Models 48 

Cognitive Behavior Therapy 49 

Brief Cognitive Behavior Therapy 51 

Using Brief Therapy with Undergraduates 53 

Undergraduate Personal Growth Concerns 55 

Individual Information Processing Differences 56 

Demographic Factors 56 

Learning Style Theory 56 

Academic Learning Styles 57 

Temperament Learning Styles 59 

Learning Style Conceptualization Comparison 60 

Measuring Information Processing 60 

Personality Attitudes 62 

Measuring personality attitudes 63 

Counseling Process and Outcome 64 

Working Alliance 65 

Measuring Therapy Outcome 66 

Application in this Study 69 

3 METHODOLOGY 71 

Statement of Purpose 71 

Hypotheses 71 

Descriptions of Variables 73 

Dependent Variables 74 

Independent Variables 74 

Population 75 

Sampling Procedures 76 

Data Collection Procedures 77 

Instrumentation 79 

Working Alliance Inventory (Client) 79 

Working Alliance Inventory (Therapist) 80 

Outcome Satisfaction Questionnaire 80 

Myers Briggs Type Indicator Form M (MBTI) 81 

Center for Innovating Teaching Experiences Learning Styles Inventory (CITE).. 83 

Demographics 84 

Data Analyses Procedures 84 

4 DATA ANALYSIS 85 

Descriptive Statistics for Dependent Measures 85 



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Participant Dependent Variables Analysis 86 

Predicted future use (participant) 88 

Level of Computer/Internet Skill 90 

Outcome Satisfaction (Participant) 91 

Working Alliance Inventory Total (Client) 92 

Working Alliance Inventory Bond (Client) 93 

Working Alliance Inventory Task (Client) 93 

Working Alliance Inventory Goal(Client) 95 

Facilitator Dependent Variable Analysis 95 

Outcome Satisfaction Questionnaire 96 

Working Alliance Inventory Total (therapist) 97 

Working Alliance Inventory Bond (therapist) 98 

Working Alliance Inventory Task (therapist) 99 

Working Alliance Inventory Goal (therapist) 101 

Qualitative Analysis 103 

5 SUMMARY, CONCLUSIONS, AND IMPLICATIONS 106 

Summary of the Study 106 

Limitations 108 

Implications and Recommendations 1 10 

Research 110 

Clinical Ill 

APPENDICES 

A FORMS AND INSTRUMENTS 114 

Participant Contact Sheet 114 

Informed Consent 115 

Outcome Satisfaction Questionnaire 117 

B FACILITATOR TRAINING MANUAL 120 

Table of Contents 120 

Logistics 121 

Session Structure Guidelines 124 

Therapy Plan and Progress Notes 127 

Facilitator Checklist 128 

Sample of tracking sheet 129 

WebCT samples screens 130 

Required Reading Study Protocol 132 

Required Reading College Student Counseling 133 



vin 



C COMPUTER-MEDIATED SESSION TRANSCRIPT 134 

LIST OF REFERENCES 144 

BIOGRAPHICAL SKETCH 160 



IX 



Abstract of Dissertation Presented to the Graduate School 

of the University of Florida in Partial Fulfillment of the 

Requirements for the Degree of Doctor of Philosophy 

PROCESS AND OUTCOME EFFICACY OF INTERNET COUNSELING 



By 

Martha Lana Bogardus Groble 
December 2002 

Chair: James Archer Jr. 
Department: Counselor Education 

This study examined the process and outcome efficacy of Internet counseling by 
comparing it to traditional face-to-face counseling in an experimental environment. We 
recruited 123 undergraduates from fourteen classes in two institutions of higher 
education. Students volunteered to participate in three personal growth sessions and 
complete five surveys. Ten graduate students were trained to conduct brief cognitive 
behavior therapy in personal growth sessions within the research protocol. Facilitators 
were trained to use the chat room and survey functions of the University's secure remote 
classroom system WebCT. 

Participants were randomly assigned to the face-to-face or computer-mediated 
condition. Facilitators conducted an equal number of sets in each condition but each 
participant was seen in only one of the two conditions. The demographic survey was 
conducted in the classroom during recruitment while the other four surveys were 
completed after the last of the three personal growth sessions in the WebCT survey site, 
whether the participant had been assigned to the face-to-face or computer-mediated 
condition. Facilitators completed two surveys after each set of sessions. 



Process efficacy was measured with the Working Alliance Inventory (WAI), 
forms client and therapist. The WAI provides a score for total alliance, and sub-scores 
for bond, task, and goal, key factors in the development of a therapeutic milieu. Outcome 
efficacy was measured with a researcher developed Outcome Satisfaction Questionnaire 
with three scales, outcome satisfaction, computer skill level, and prediction of likelihood 
of future use of computer-mediated counseling. 

The independent demographic variables, age, ethnicity and gender, were collected 
from the contact information form completed during recruitment. Learning style 
preference was determined using the CITE. Learning Styles Inventory and the Meyers 
Briggs Type Indicator (MBTI). Personality attitude preference - introversion or 
extraversion - was determined using the MBTI. 

Significant main effects were found for the academic learning style systems and 
for gender. Significant interactions were found for gender by condition indicating that 
males reported greater process ability in the face-to-face condition contrary to a study 
hypothesis. No significant results were found for age, ethnicity, introversion/ 
extraversion or research condition. Recommendations for further research and clinical 
applications are discussed. 



XI 






CHAPTER 1 
INTRODUCTION 



At the dawn of the 20 th century, the fledgling professions of psychiatry, 
psychology and counseling were beginning. As the 21 st century begins a radically 
different service delivery method, which may in fact generate a radically new helping 
profession, is occurring. The current world population of Internet users is estimated to be 
around 349 million and growing (Stubbs 2000). A segment of these users are accessing 
mental health services variously known as Telecommunications, Telehealth, and 
Telemedicine. Telecontact, between a mental health provider and a mental health 
consumer, may simply be a plain old phone call, to reassure a patient that his or her 
medication has been called into the pharmacy; a copy of an e-mail of a typical interaction 
with a troublesome relative, which records the transactions while they are fresh, for 
processing in the next scheduled therapy session; peer moderated bulletin board support 
groups; video conferencing to train parents how to care for children with seizure 
disorders; live, interactive Internet dream work with a renowned dream therapist; or a 
very complex, surrealistic virtual reality counseling world. Computer-mediated 
counseling is in its infancy. However the generic and programming code necessary to 
bring it to maturity is already in place for interactive, graphic (sound, visual, and 
animated) virtual worlds where clients can choose avatars or symbols to represent 
themselves and to characterize the psychotherapy issues salient to their needs. 



Although the technology and evolution of virtual reality are 30 years old, its 
application in counseling has not yet been significantly engaged. The virtual counseling 
world is the quintessential postmodern constructionist therapy environment. Fink (1999, 
pp. 28-29) reasoned, "computer-mediated communication (CMC), clearly a postmodern 
phenomenon, are a form identified by the mediator (the computer) as well as by the 
communicator (the virtual ego). The machine determines existence. . . . (u)sing present 
technology, CMC tends to be fluid, cycling, and devoid of social cues, which constitute 
modernity. Accordingly, psychotherapy that uses CMC is also amorphous, shifting in 
response to context, technology and the nature of patient interaction." In essence, the 
counselor and client co-create the cyber counseling experience in the material processed - 
behavioral issues, distorted thoughts, troubling problems, faulty cognitions, 
overwhelming emotions - and in the very essence each participant chooses to contribute 
to the structure of the working space. Language, spoken or written, forms the connection 
between two people. Stanley (2001) argued that "rather than language being a reflection 
or mirror of social life, language itself constructs social life when it is practiced. 
Discourses produce different versions of this social life, different realities. The goal of 
discourse analysis then is not to improve upon people's accounts, but rather to understand 
how they are practically achieved." 

Much of the power differential between client and counselor dissipates when each 
presents without the hallmarks of embodied age, race, gender, physical attractiveness, 
size and shape, native language, dialect, speech impediments, or peculiar mannerisms, 
which color and may distort face-to-face communication with preconceived stereotypes 
and subtle biases. For example, the researcher had a revealing chat experience with an 



American living in Iceland. This was a personal recreational activity, not a professional 
relationship. While both were using an AOL Dream chat channel, the person in Iceland 
"popped-in" to the researcher's screen via the private channel (instant messenger) when 
the researcher mentioned that she lived in Jacksonville, Florida. The person in Iceland 
had moved from Jacksonville Naval Air Station to the Iceland Naval Air Station and was 
lonely. The researcher was familiar with both geographic locations, both Naval Air 
Stations and with military-family life. The researcher assumed that the person with 
whom she was chatting was a young wife of an enlisted sailor. The chat contents were 
volcanoes, glaciers, lava beds, hot water lagoons, things to do in Reykjavik, Icelandic 
mythology, other exotic locations familiar to both. The researcher terminated the 
interaction when she learned that her cyber-friend was a 12-year-old girl. Nothing had 
ever been discussed that was inappropriate when talking with a child. Nothing had ever 
been discussed that the researcher had not discussed with hundreds of children that age 
during her career as a natural history museum curator; however, a personal bias of how, 
or when or for what reasons one related to a child had been violated (a surprising 
revelation to the researcher). The girl in Iceland had never claimed to be anything other 
than what she was — a situationally lonely and resourceful kid who moved all too 
frequently to become rooted in any conventional community, a person regardless of age 
who was interested in relationship, friendship, computer communication and natural 
history. One would think that age should not matter in this situation but it did. Most 
saliently, it is precisely for this population (the geographically isolated) that telehealth, 
telemedicine, and cyber-counseling are most strongly advocated. In the more formal 
setting of cyber-counseling, intake information would provide basic information — if the 



4 



client chose to respond accurately. However, in virtual reality one can role play age, 
race, gender, physical attributes and try on a vast range of solutions from which to select 
practical ideas to apply in his or her social-gravity bound life. The counselor in virtual 
sessions will not only be aware that the client may be role-playing but will need to 
develop new theory which promotes and capitalizes on a therapeutic world free from 
factors that often may actually be the source of the clients' distress. This radical new 
formulation of therapy may be analogous in the physical sciences to work done in space 
in the absence of gravity. Obviously one does not live long in the absence of gravity 
without serious physical consequences (e.g., loss of bone mass and tissue density). 
However, as a special condition to accomplish a specific end (e.g., re-growing tissue 
more quickly and with less pain) it has therapeutic advantages heretofore unavailable in 
theory or in practice. The powerful value of such study is clearly demonstrated by a 
global community's willingness to engaged in the high risk, construction of our third 
multibillion-dollar facility for such research — the International Space Station (preceded 
by Skylab and Mir). 

Cyber counseling therapy in the absence of the weight and pressure of social 
markers allows a healing space, not a long-term residence for the client. Just as NASA 
researchers and their Russian counterparts must experiment and learn about the 
weightless environment available in near outer space, mental health researchers must 
experiment and learn about the social and relational weightlessness of cyberspace. 
Cyberspace then presents the constructionist need for a completely new theory of 
counseling, a completely new way of thinking about counseling, not just a new delivery 
system. 



Entering cyberspace, then, disembodies the counselor and the client. In therapy 
in cyberspace, the nature of the interaction first deconstructs the everyday givens of the 
counselor and client, then the two co-construct a new healing reality through the 
therapeutic dialogue. Is that not the crux of psychotherapy - helping, guiding, 
facilitating, and coaching clients to discover, learn, or experience their story, their inner 
dialogue in a new, more self sustaining way? The major mental health professional 
organizations (National Board of Certified Counselors, American Counseling 
Association, American Psychiatric Association, American Medical Information 
Association, American Psychological Association, Commission on Rehabilitation 
Counselor Certification) agree that now, in the infancy of Internet counseling is the time 
to set the values, ethics and discipline of this new opportunity (NBCC 1997, NBCC 2001, 
APA 1997, AMIA 1998, ACA 1999, APA 2001, CRCC 2002). 

Virtual Psychotherapy will have as little in common with the theory, context, 
content, and outcome of contemporary psychotherapy as contemporary psychotherapy 
has with priests and shamans. In the pre-modern or pre-science era, priests and shamans 
healed physical, emotional, and spiritual distress based on observations and beliefs about 
the natural and supernatural world, using plant materials, astronomical observations, 
beliefs about supernatural interventions and such. In the 1990s and 2000s these 
ceremonies continue but it is unlikely that Blue Cross Blue Shield or any other third party 
payer would assume financial responsibility for a Sufi whirling dervish, a Greek 
Orthodox exorcism, a Pentecostal spiritual slaying, an Episcopalian laying on of hands 
healing service, a Sunni (Lapland) sweat lodge, a Kiowa medicine wheel, a Lakota 
buffalo hide ceremony, Saginaw Chippewa eagle feature ceremony, yogi fire walking 



treatment, or a Huichol peyote ceremony, even though these practices are far more 
ancient and continuous than modern psychology and have anecdotal efficacy (which, 
admittedly, is difficult to quantify). In the modern era of scientific understanding and 
explanations, physical illness and emotional distress have been dichotomized and 
spiritual meaning has been severed from the treatment arena. Postmodern 
disappointment with the limitations of science has revisited issues of holistic medicine, 
prayer, faith, sympathetic magic (e.g., crystals), imitative magic (e.g., smoke, feathers) 
and worldview in the relief of distress. The same is projected for the postmodern era and 
cyber counseling. 

Notably, all pre-modern and modern treatments recognize the value of a helping 
relationship between the helper and the person seeking help, and a satisfactory outcome. 
The outcome must be satisfactory in many or most cases or the method would have 
become extinct, or at least superceded by major reformulation (e.g., trepanning to high 
technology brain surgery, leaches to lancing). 

Disembodied, asynchronous, and globally accessible therapeutic models will 
expand the limits of thought and theory about the necessary and sufficient conditions of 
therapy and the nature of therapy. Language and overt self expression have always been 
the working matter of counseling — i.e., Freud's talking cure — however, language and 
imagination will predominate in cyber counseling and will require new 
conceptualizations of the essence of language in a polyglot world community (Shorter 
1993). The language of the Internet is English, American English (Fink 1999). English is 
the lingua franca of commerce and science. Internet therapy were influenced, limited and 
contaminated for clients whose native language is not English even though they may 



have learned English in a country or culture that places high value on knowing English 
and teaches it beginning in first grade. 

English as a second language has been identified as a multicultural issue in 
counseling. How much greater will this issue become, in a global environment? 
Counseling laws, where they exist, tend to confine counseling to the state of the 
therapist's licensure; however, there are no International constraints. A potential client 
can be asked to affirm that she or he lives in the state of the therapist's licensure. 
However that does not mean that the person does, or if he or she does that he or she lives 
in an acculturated community. If a person's English or Spanish appears to be adequate to 
the counseling demands, can we assume that the person is keying in his or her comments 
directly through the computer, or is the client talking to a typist who enters the 
comments, or to a translator who must interpret both sides of the communication 
inadvertently and subtly changing each side. Web cam technology offers some solutions, 
or hope for solutions to the disembodied and perhaps linguistic problems posed in 
Internet counseling. An area of counseling is likely to evolve in the virtual reality model 
that is independent of physical and verbal cues. 

Virtual reality models and virtual reality role playing have 30 years of history and 
refinement from the worlds of virtual gaming and virtual socializing. Fundamental issues 
of human presences, viability, efficacy, ethics, limitations, indications, contraindications, 
national and international licensing and liability and risks to clients must be thoughtfully 
discussed, debated and researched. 

Scope of the Problem 

Psychotherapists are using the Internet to provide a full range of mental health 
services. Powell (1998) surveyed licensed Internet counselors listed on the Metanoia 



8 

website. She learned that the 13 respondents served 445 clients in 1995, 947 clients in 
1996, and 1344 clients in 1997. Over 15,000 health care related web sites were reported 
in 2000 (Dunaway 2000). While many of these are telehealth and referral, if only 5% are 
counseling and therapy sites, and if 1997 statistics are applied to that 5%, nearly 100,000 
clients are presently receiving mental health services via the Internet in the absence of 
empirical data to support the efficacy of this service. Of Powell's respondents, 85% 
primarily used email for their Internet service; however 33% of these counselors had chat 
capability and none were using virtual reality technology. These figures do not include 
peer-moderated electronic bulletin board, peer-moderated chat rooms and private 
messages. 

Counseling issues included relationship issues, depression, family issues, 
substance abuse, and anxiety (Powell 1998). In 2001, the organizers of the 
HealthyPlace.com website both list and recruit mental health professions, creating a 
network of referrals and some measure of credential verification. Members are 
encouraged to provide supervised web sites, called communities, in the areas of abuse; 
ADD/ ADHD; addictions; alternative mental health; anxiety and panic disorder; bipolar 
disorder; chronic pain; depression; dieting; eating disorders; gay, lesbian and transgender 
issues; obsessive-compulsive disorder; parenting; personality disorders; relationship; self 
injury; and sex/sexuality. "Partners" are encouraged to manage a complete website, write 
a topic specific column, be the community's "ask-a-doc" columnist, maintain a 
journal/diary, manage an e-zine or write an Internet newsletter. Holmes (2001) whose 
screening appears to be more selective, has links to over 700 counseling sites The owners 



ofPsychnet.com sell mental health related domain and the tools to develop them at 
http://www.psychnet.com. 

Concerned professionals began researching the Internet services, even before the 
Internet became available to the public in 1994 (Colon 1994). Professional organizations 
have been debating salient issues (Holmes 1997). The federal government has passed a 
telehealth bill (U.S. Congress 1997, HCFA, 1996, HCFA, 1999). In 1997 the state of 
California enacted the first state law restricting California therapists to in-state Internet 
clients (Maheu 2001). The American Counseling Association researched current practice 
in distance learning related to mental health and cyber counseling. A major 
recommendation from that study was the need for research in the area of cyber 
counseling (Brown & Walz 2000). Cyber counseling research must build the theoretical 
foundation and constructs of Internet communication and of mental health counseling. 

Theoretical Framework 

The theoretic framework for this study consists of the constructs of social 
presence, (Lombard 1997, Reid, 1994), trustworthiness (Edwards 2000) and intimacy 
(Robson 1998) in cyberspace, counseling in cyberspace, person centered alliance building 
skills, brief counseling, learning styles, and personality traits. "Psychotherapy is a human 
relationship that heals" (Suler 1999). For a relationship to develop both participants must 
be involved in a personal, dynamic manner. Earliest theories of the Internet as simply an 
impersonal source of information were quickly replaced by the information foraging 
cognitive model (Priolli 1999), the sociological "gathering and communicating model" 
(Sproull 1997) and the anthropological expanding human experience: - understanding 
artifacts, and culture model (Mantovani 2001) to better reflect the evolution of Internet 
use and the experience of Internet users. The Social Presence Theory is a micro theory 



10 

that identifies six components of social presence, a prerequisite to interpersonal 
relationship on the Internet and, therefore, a prerequisite to Internet counseling - social 
warmness, realism, transportation - "you are there," "we are there," perceptual and 
psychological immersion, social actor within the medium, and medium as social actor 
(Lombard 1997). Almost all counseling theories emphasize the importance of the 
interpersonal relationship between the counselor and the clients, although they may vary 
in the manner in which they deal with the helping relationship, transference, counter 
transference, or working alliance. It is reasonable then to infer that social presence is a 
key concept for the development and evaluation of Internet counseling. It should be 
noted that several projects have attempted to create computer-as-counselor (Wizenbaum 
1966, Maes 1995, Ookita, 2001). However, this study examines the human counselor 
client interaction with computer as communication mediator. Computer-mediated 
communications is not, in and of itself, psychotherapy, no matter how personal, 
rewarding, helpful and satisfying it may be. Hampton and Houser emphasized that "the 
Internet is a tool and it has no more inherent ability to cause harm than a telephone. Like 
other tools, if we use it properly, it will be helpful and beneficial. However, if we misuse 
it, the consequences will be detrimental (Hampton 2000)." A century of research and 
application have demonstrated that psychotherapy is a particular form of communication 
supported by heuristic theory, discrete techniques, and demonstrable outcome results. 
Now research must do the same for computer-mediated communication so that Internet 
counseling will be helpful and beneficial rather than detrimental. 

This study was designed to contribute to that needed body of research. To do so, 
the study compared brief cognitive behavioral theory applied in personal growth 



11 

session's used in two conditions, face-to-face or computer-mediated sessions. Cognitive 
behavioral theory defines and describes salient constructs as cognitive events, cognitive 
processes, and cognitive structures (Meichenbaum 1988, Meichenbaum 2000). Cognitive 
events are conscious, identifiable or readily retrieved thoughts, images, and 
accompanying feelings. These events include internal dialogue, expectations, espoused 
beliefs, and appraisals. Cognitive events occur when the person's automatic behavior is 
interrupted, when one is uncertain about making a choice or judgment, when one is 
troubleshooting, and when one is exercising recall or reconstruction of an event or idea. 

Cognitive processes are defined as the way a person processes information. 
These processes include information storage, search, retrieval and application. Cognitive 
theory suggests that information is received, encoded, stored, retrieved and applied to a 
given situation based on the beliefs and values of the individual. That is, not all possible 
information, which one encounters, is stored or retrieved. There is a selection process 
based on salient beliefs and values. An artist, for example, may store shape, form, color, 
light, and texture information extant in the everyday world, which others would miss 
entirely. The artist can retrieve that information in another setting because it is relevant 
to his or her worldview. At least three of these cognitive processes, confirmatory bias, 
mental heuristics, and meta-cognition, are important in psychotherapy. Confirmatory 
bias is a process by which the person stores and retrieves information that confirms a 
belief or value without questioning the underlying belief. Using this process, the 
individual filters out any contrary information or ambiguous information, denying that 
individual necessary information in the current situation. Mental heuristics are processes 
or templates for making decisions in ambiguous situations. Stereotyping is a common 



12 

mental heuristic. Meta-cognitions are ways of thinking about and controlling cognitive 
processes. Scarlett O'Hara's "tomorrow is another day" or little orphan Annie's "the sun 
will come out tomorrow" are meta-cognitions, cognitive processes or templates that 
automatically inform that believer to ignore today's disappointments, fears, worries, and 
concerns because they were gone tomorrow. Cognitive structures or schemes are 
templates that are pervasive, readily accessible, and reflect personal themes. 

Each theory of psychotherapy has generated techniques or procedures, that use, 
operationalize, and/or apply the theory in concrete situations with particular clients. Beck 
and his colleagues (Beck 1979) emphasized that cognitive behavioral therapy is 
collaborative work, which begins with rapport. To develop this working relationship, 
they recommend that a good base for building of rapport is simple courtesy — not 
keeping the patient waiting, remembering important facts about him, and giving a 
sincerely warm (but not effusive) greeting. Maintaining eye contact, following the 
content of the patient's talk, trying to infer and reflect the patient's feelings, and phrasing 
questions and comments diplomatically help to build rapport. The choice of words and 
labels is important (p. 53). For example, "non-productive ideas" is preferable to 
"neurotic," "sick," or "irrational" thinking. The working relationship in cognitive 
behavior therapy, however, is more than rapport building, which can be accomplished in 
a hierarchical relationship as well as in a collaborative relationship. In a cognitive 
behavior therapeutic relationship, the therapist and patient work together to determine 
how and what the patient thinks, the basis for such thinking, and the practical benefits 
and losses that result from such thinking. The patient's unique contribution to this 
collaborative effort is to provide the raw data for this inquiry, that is, to report his 



13 

thoughts, feelings, hopes, dreams and wishes. The therapist's special contribution is to 
guide the patient about what data to collect and how to utilize these data therapeutically 
(p. 54). Other collaborative techniques include "authenticating introspective data", " 
investigating underlying assumptions," "setting up experiments", and "homework 
assignments" all of which are conceptualized as making the client his or her own 'folk' 
scientist whose research is focused on his or her own best interest, personal problem 
solving and successful living. 

The process of therapy and the outcome satisfaction as reported by both the 
participant and the facilitator were evaluated to determine the efficacy of computer- 
mediated counseling. A therapy outcome is related to both what happens during the 
therapeutic process and what the participants bring to the process. This study examined 
cultural factors and personality traits that the client brings to the therapeutic process, 
gender, ethnicity, learning style, and personality traits. 

Learning style theory, an operational application of information processing 
research, is an important construct that identifies inherent learning strength and examines 
differential sensory and social ways in that people prefer to learn and learn most 
successfully (Babich 1976). Personality traits or the hard wiring of individual differences 
in attitude, response to the stimuli, collection of information from the world and source of 
energy and authority were simultaneously suggested by Jung and by the mother daughter 
team, Myers and Briggs. Myers and Briggs (Myers 1962) operationalized Jung's theory 
in the Myers Briggs Type Indicator (MBTI). Of particular interest in this study is the 
introversion/extroversion scale, because Reid (1994) and Fink (1999) each suggested that 
computer-mediated communication favors those with an introverted attitude. Jungians 



14 

have researched temperaments and their contribution to the manner in which people 
prefer to learn either in a formal educational setting or in life in general. This more 
pervasive learning style was examined as well as the academic specific learning style 
developed by the Wichita Public School System. Computer-mediated communication, 
computer-mediated social presence, cognitive events, cognitive processes, cognitive 
schemas, learning style, personality type, and working alliance are the major constructs 
that form the theoretical foundation of this study. 

Statement of the Problem 
It has long been the sin qua non of the helping professions to "Do No Harm". 
Clients seek counseling because they perceive it offers hope, help, assistance, and 
guidance in a time of confusion, pain, loneliness, or danger. Professional and 
governmental agents exist to assure clients that the professional from whom they seek 
help is trained, qualified and practicing in a safe and proven manner. Insurance 
companies and other third party payers often refuse to reimburse any treatment that is 
considered unproven or experimental. When new methods are developed, they must be 
reproducible and scrutinized by the professional community to insure that they are safe 
and effective. It cannot be assumed that when there is major change in the manner in a 
service is provided, the therapy is identical to previously validated methods. Internet 
counseling must meet the same standard of applicability and efficacy that is required of 
all other modes and forms of counseling. Research must inform clinicians regarding 
appropriate selection of clients who are likely to benefit from Internet counseling and 
must demonstrate useful theory and techniques in the cyberspace-counseling 
environment. One size does not fit all, and one technology certainly does not fit all. 



15 

Purpose of the Study 

The purpose of this study was to compare and contrast the development of 
working alliance (Horvath 1993, Horvath & Greenberg 1986, Horvath & Mars 1991, 
Horvath & Symond 1991), and outcome satisfaction with traditional face-to-face brief 
group counseling and with computer-mediated brief group counseling. The effects of 
learning style (Babich 1976) and personality traits were analyzed to determine if potential 
differential efficacy of face-to-face or computer-mediated counseling could be predicted. 
The study will examine which, if any, specific learning style and personality traits are 
predictive of success in one modality or the other. 

Need for the Study 

Few studies exist to guide psychotherapists who decide to move all or part of their 
practice to the Internet. Most of these studies are surveys and other qualitative studies as 
is appropriate for developing heuristic for a new area of inquiry (Barak 1999, Colon 
1994, Dunaway 2000, Fink 1999, Harris-Bowsbey 2000, Stubbs 2000). Virtual Reality 
(VR), the high end of Internet technology is being studied with statistical rigor in the 
treatment of phobias (North 1994, Rothbaum 1997), cardiac illness in children (Bers 
1997), and chronic pain at a burn clinic (Patterson & Hoffman 2000). Ethics working 
papers and guidelines exists to structure Internet psychotherapy (NBCC 1997, AC A 
1999, AMIA 1998, APA 1997, Brown & Walz 2000, Holmes 1997, NBCC 2000, CRCC 
2001) and there is no dearth of technology and technical assistance to develop and market 
Internet therapy. There is however, a critical need for empirical research to analyze 
typical Internet therapy after almost a decade of development. 

The primary therapeutic use of the Internet appears to be Internet support groups 
(King 1998). Because of this widespread use, the American Psychological Association 



16 

conducted an Internet support group symposium at their annual convention. Barak and 
Wander-Schwartz (1999) report one of the only studies of Internet therapy. They 
describe their study as preliminary, warned that its findings should be interpreted with 
caution and called for intensive research. Several professional and scientific questions of 
relevance include: Is Internet therapy useful, beneficial, satisfactory, and efficacious? Is 
Internet therapy harmful? Does Internet therapy immunize potential clients to effective 
face-to-face treatment? Is Internet therapy a technology placebo? Is Internet therapy 
"snake oil"? Do the personality traits of the client influence the effectiveness of Internet 
counseling? Is the Internet, as one author suggests, "revenge of the introvert?" Is a 
visual learning style more conducive to effective Internet results than a verbal learning 
style? Does the physical isolation of computer-mediated psychotherapy hamper the 
success for clients with social group learning style preference? These are but a few of the 
questions that need to be considered, especially if the cyber client is to be provided with 
appropriate services, the psychotherapist is to remain in compliance with his or her 
professional ethics and credentials, and if the insurance industry is to recognize and 
reimburse Internet therapy. 

Rationale for the Study 
This work contributes to the foundation for the lower end technology interface. It 
will benefit counselors who wish to work well and ethically Internet. With this and 
similar research, counselors will have tools to determine which clients are best served by 
Internet counseling, and which clients need to be seen face-to-face. It will benefit clients 
who are geographically or situationally isolated from counseling services to be able to 
make an informed decision about Internet counseling. Since the federal government 
health benefit program has long supported some forms of telehealth and telemedicine as a 



17 

cost- containment means, a strong research effort is needed to support the claims of 
counselors and clients for third-party payment. 

Research Questions 

The following six research questions were examined in this study: 

1 . Is brief, Internet counseling as effective as brief face-to-face counseling? 

2. Does working alliance develop equally well in brief, Internet counseling and in 
face-to-face counseling? 

3 . Does the information processing style (visualizing/verbalizing) of a 
participant influence the effectiveness of Internet brief cognitive counseling? 

4. Do personality attitudes (introversion/extroversion) of client affect the 
efficacy of Internet brief cognitive counseling? 

5. Does the ethnicity of the client affect the efficacy of Internet brief 
counseling? 

6. Does the gender of the client affect the efficacy of brief cognitive Internet 
counseling 

Definition of Terms 

Counseling terms 

Learning style — the sensory and social process by which an individual acquires, 
encodes, stores, and retrieves information, including visual, verbal, kinesthetic, tactile, 
social-individual, social-group, expressive-oral and expressive- written (Babich 1976). 
Personality Traits — as defined by Jung (1923) these are psychological functions of 
thinking, feeling, sensing, and intuiting, which interact with attitudes of introversion and 
extroversion. Myers (1962) added the constructs of judging or perceiving (cf. MBTI). 
Each individual has preferred functions and attitudes that he or she generally prefers to 
use to collect information about, and interacts with his or her intrapersonal and 
interpersonal environment. 



18 

Working Alliance — the therapeutic relationship that develops in the counseling 
environment to facilitate success. Three components of the working alliance are the bond 
between client and counselor, mutual agreement on the goal of therapy, and mutual 
agreement on the tasks of therapy that will accomplish the goal (Bordin 1976). 

Computer Terms 

Synchronous — (antonym asynchronous ) means happening at the same time or moving at 

the same rate of speed or having the same rate and phase as vibrations (Gurainik 1979). 

These are key concepts in Internet communication and refer to the ability of people to 

communicate at the same time (synchronous) from any computer in the world or near 

outer space or to communicate at different times (asynchronous). Examples of 

synchronous interactions are text chat and media chat. Email and bulletin board 

discussions are asynchronous. (Suler 1999). 

Chat — real time, live, or synchronous text conversation between two or more people 

located at a computer keyboard anywhere on the planet or in near outer space. (Young, 

1998) 

Cyberspace — a term coined by science fiction writer William Gibson (1984) to describe 

the space that exists between people, computers, satellites and phone lines 

E-mail — generally one to one written "letters" but courtesy copies, blind courtesy 

copies, and group mailing are also common (Young 1998). 

Encryption — applying mathematical algorithm to plain text to produce apparently 

unintelligible text for security purposes during transmission (Smith 1997). 

Telehealth/telemedicine — developed originally by NASA (2001) in the early 1960's to 

provide health care and monitoring for astronauts, beginning with Project Mercury. It 



19 

provides assistance in disaster stricken areas throughout the world and applies space- 
based technology to terrestrial medical care. 

URL — the address or location of information on the Internet. The acronym stands for 
Universal Resource Locator (Young 1998), although Berner-Lee (2000), a particle 
physicist who created the World Wide Web, originally used URI for Uniform Resource 
Identification and the terms are often confused because the URI is still used for addresses 
on the Internet outside the worldwide web. The URL of a popular search engine for 
example is http ://www. google. com. While most clients will see the URL, the direct form 
is http://216.199.19.139/ the URI of a small business in Jacksonville. An email address is 
not a URL or a URI but rather a hyperlink to a section (bin) within the service provider's 
website. 

Virtual Reality (VR) — immersion technology currently being used at MIT and 
elsewhere to treat pain and phobias. VR is a graphic and animation rich computer 
environment, which simulates visual, auditory and tactile sensations. For 
microcomputers, (PCs and Macs) VR uses MOO (MUD Object Orientation) virtual 
reality programming code that allows the creation, use, and manipulation of items on the 
screen. MUD is Multi-User Dungeons, (now also Multi-User Domains, Multi-User 
Dimensions) a virtual world originally developed in the 1970s and 1980s for playing 
adventure role-playing games. MUSH is Multi-User Shell, a programming system that 
allows users to develop and manage either an adventure or a social MUD (Bruckman 
1995). This technology can potentially be used to develop VR counseling from any 
computer given adequate bandwidth and baud rate to both the counselor and client 
computers. 



20 

Organization of the Study 
This study consists of five chapters, an abstract, three appendices, and a list of 
references. The abstract and introduction present the Internet and counseling context for 
the study describing research issues of the growth and professional concerns about 
Internet counseling. The second chapter reviews relevant scholarly literature on social 
presence, Internet counseling, face-to-face brief counseling, working alliance measures, 
outcome efficacy measures, learning styles and personality traits. The third chapter 
describes the structure of the study, characteristics of the participants, dependent and 
independent variables observed, measures used, and statistical procedures applied to 
analyzing the results of the experiment. Chapter four presents the statistical results and 
chapter five discusses the significant results, potential impact to Internet counseling, 
limitations of the study, and recommendations for Internet counseling and further 
research. The appendices contain forms and measures created for this project, protocol 
for facilitator training and sessions, and a sample computer-mediated session transcript. 



REVIEW OF LITERATURE 

The relevant scholarly literature is reviewed in this chapter. Topics to be reviewed 
are research; Internet computer counseling concepts; Cognitive counseling theories; 
personality traits; temperament learning style; academic learning style, and counseling 
outcome and process theory. The exiting Internet research, which is primarily qualitative 
and heuristic, addressed the social and cultural dimension of Internet transaction and the 
construct of social presence on the Internet, a prerequisite to counseling. The advantages 
and concerns about Internet counseling as discussed by the mental health professional 
organizations and activists, and current applications of counseling on the Internet. While 
outcome efficacy of Internet counseling is a concern in all theoretical approaches, for the 
purposes of this study, the theory used is brief cognitive behavior therapy. Research 
regarding basic precepts of cognitive behavioral therapy, basic precepts of brief therapy 
and the construct of working alliance are reviewed. Relevant research about personality 
traits, theory and application of learning styles are discussed as related to independent 
variables in this study. The theory and instrumentation for evaluating the independent 
(personality type and information processing style) and dependent (working alliance and 
outcome) variables are presented. This chapter concludes with a discussion of the 
contribution of the existing research to the formulation of the present study. 

Internet Counseling Basic Constructs 

To counsel in cyberspace, one must first assess the constructs and theories 
defining human relations in cyberspace. Counseling is a human interaction, which is a 

21 



22 

good deal more complex than ordering a book from Amazon.com or a rose bush from 
JacksonandPerkins.com. Is there a subjective component to human interaction in 
cyberspace? Is there a "person" or "psyche" to counsel? Three major concepts have 
been discussed at length - social presence, trustworthiness and intimacy. These factors 
create an environment in which a therapeutic alliance can be developed. One of the three 
essential components of a therapeutic alliance is the development of a personal bond. 
Social presence, trust, and intimacy or self-disclosure, create the milieu in which a 
personal bond can develop between the therapist and client. The client and the counselor 
need to experience a sense of bond, connection, or rapport. The bond can be based on 
the sense of mutual trust, liking, understanding and care (Bordin 1976, Horvath & 
Greenberg 1986). 
Social Presence. 

Is there social presence in cyberspace, and if so, how does it manifest? In 
response to the gamut of pressures emanating from the war in Viet Nam and the Cold 
War, government, military and related universities developed the technology to deliver 
information around the world and into near outer space almost instantly. At the same 
time, social, political, humanitarian and radical thinkers were developing experiments in 
human living that were just as dramatic. The social geniuses of the era readily adapted 
and defined the ultimate use of the Internet. Rheingold (1994) was perhaps the first 
social thinker to systematically describe the social and cultural communities that 
developed on the Internet. The WELL, a San Francisco founded, Internet community 
dating from the early 1980s, grew out of the social activism, communal living 
experiments, and democratic philosophies of the 1960s. The personal involvement and 



23 

real life connection among members is illustrated in the following two incidents. The 

WELL community organized a massive medical resource location, medicine delivery, 

and member return transportation from India to San Francisco when a former member 

who had become a Tibetan nun developed a rare liver condition and was destined to die 

in India without this heroic, real time, real cash, real resource, unbidden, but greatly 

appreciated massive intervention (28-32). 

In another case, a prolific member of the WELL committed Internet suicide, the 

act of removing all of his years of comments and conversations written into the fabric of 

the community. Alert members of the community called him, assured that he sought and 

received professional help, and notified his family and other friends. In the end, the 

effort was insufficient and the member committed real world suicide. Rheingold mused 

"Suicide brings up unusual feelings in any family or 
social group. Fortunately, there were one or two 
among us who knew exactly how to understand what 
was happening to us: a fellow who had struggled with 
years of feelings over his brother's suicide was able to 
offer wise and caring and credible counsel to many of 
us. 

There was a real-life funeral, where we brought our 
physical bodies and embraced each other and Blair's 
family. We were learning how fond we had grown of 
Blair, and how his death put a milestone in cyberspace. 
Marriages had happened and others had unraveled. 
Businesses had started and failed. We had parties and 
picnics. But death seems somehow more real, even if 
your only participation is in the virtual funeral. How 
could any of us who looked each other in the eye that 
afternoon in the funeral home deny that the bonds 
between us were growing into something real? The 
feelings ran just as high during the virtual part of the 
grieving rituals as they did during the face-to-face part 
- indeed, with many of the social constraints of proper 
funeral behavior removed, the Internet version was the 
occasion for venting of anger that would have been 
inappropriate in the face-to-face gathering. There 



And 



24 

were those who passionately and persistently accused 
the eulogizers of exhibiting a hypocrisy that stank unto 
the heavens, because of our not altogether charitable 
treatment of Blair Internet when he was alive. 
Those of us who had made the calls to Blair and his 

shrinks, who went out and met his brother and his 

mother and tried to provide them some comfort, had a 

different attitude toward those who couldn't bring 

themselves to attend the painful event in person but 

didn't hesitate to heckle others Internet. People who 

had to live with each other, because they were all 

veteran addicts of the same social space, found 

themselves disliking one another (p. 37)." 

" There has always been a lot of conflict in the 
WELL, breaking out into regular flamefest of 
interpersonal attacks from time to time. Factionalism, 
Gossip. Envy. Jealousy. Feuds. Brawls. Hard feelings 
that carry over from one discussion to another (p. 53)." 

Thought, feelings, and behaviors are the raw materials of counseling. 
Rheingold's experiences provide poignant insights into the thoughts, feelings and 
behaviors Internet and in the real life of a multinational, Internet, social community. 
From social psychology, the construct of disembodied engagement and personal 
interaction over the Internet has been named "presence". Lombard and Ditton (1997) 
identify presence as the sense that mediated experience (computer, simulation rides, 
home theater, video conferencing) is natural, immediate, direct, real and unmediated. 
This qualitative factor of mediated communication is crucial to community building and 
counseling. "An enhanced sense of presence is central to the use, and therefore the 
usefulness and profitability, of the new technologies... These technologies either are now 
changing or are expected soon to change many of the ways we work, play and live (p. 
2)." Social presence theory was studied early in the advent of mass, affordable access to 
electronic media and continue to be important in social psychology and mass 
communication research. 



25 

Cyber feminist Plant (1996) warned that the Internet disembodies, degenderizes 
and promotes yet another form of oppression. Stanley (2001) and others (McLuhan & 
Friore 1967, Billig 1996, Shotter, 1993, Turkle, 1995) countered that language embodies 
the authentic self and depoliticalizes the communication. Stanley disputed the concept of 
virtual space saying, "a social space (is) constructed through which embodiment could be 
revealed. This reality is "real space," the space that is on the other side of the screen . . . 
real space constitutes the embodied practice of social talk (p. 77)." He suggested 
interpersonal life is a dynamic performance of language constructed in speaking and 
writing, not in thinking or holding unexpressed opinions and attitudes. "Rather than 
language being a reflection or mirror of social life, language itself constructs social life 
when it is practiced. Discourses produce different versions of this social life, different 
realities (p. 79)." Stanley works with international students for whom life with family 
and friends of necessity is text based. He analyzed the text-based interviews with distant 
students/participants and identified recurring themes. Quotation marks are used to signal 
'stake' and 'accountability. Subjectivity and reality, marked by the use of "humm" and 
"erm", Stanley noted is "an archetype of phonetic space (that) has been appropriated for 
use in cyberspace (p. 86)." He found that the bodily presence of the person using the 
Internet is present in the use of emoticons (emotion icons) and by typing speed, pauses, 
and deletions. Language itself embodies in metaphorical phrases. Boechler(2001) 
makes much the same argument from a cognitive process and concept point of view. 

Much of the debate over presence and embodiment (Harris-Bowlsbey 2000, King 
& Moreggi 1998, Laszlo, Esterman, & Zabko 1999, Miller 1995, Plant 1996, Powell 
1998, Reid 1994, Suler 1999, Walther 1996) has or needs to examine how presence, 



26 

emotion and embodiment are incorporated in text-based communications. Letters, 
missives and discourses were the major form of communication from the invention of 
writing at least as early as 5,000 B.C.E. until the invention of the telephone, telegraph, 
and radio in the last 19 th century (Bell 1867, Bell 1895, and Marconi 1900). The most 
common and wide spread convention for expressing emotion on the Internet is the smiley 
or alternately the emoticon. Early on, the need to encode and covey feelings was 
recognized in the computer chat space. Carnegie Mellon Principal Research Scientist, 
Scott Fahlman, (1995) admits 

"Yes, I am the one who first suggested the use of the :-) 
and :-( glyphs in E-mail and bboard posts sometime around 
1981 . People were making sarcastic comments in posts, 
others were taking them more seriously than they were 
intended (no body language on the net), and silly arguments 
were breaking out. So I suggested on one of the CMU 
bboards that people explicitly label comments not meant to 
be serious with a :-) glyph. Very quickly, this idea spread 
all around the world and others started creating clever 
variations on the theme. The awful term "emoticons" is 
much more recent." 

These glyphs (see Z'Boray 1997) are an important part of routine Internet 

socializing but are inadequate for expressing the range of non-verbal cues necessary in 

counseling. Other rules of appropriate behavior (netiquette) on the Internet also evolved 

to smooth social interactions (Rinadli 1998) and should be observed by the cyber 

counselor but like glyphs, netiquette is not sufficient for the needs of the counseling 

relationship. The introduction and development of glyphs and netiquette demonstrate 

that the need and convention was recognized early in the development of text-based 

communications. 



27 

Cyber counseling specific conventions have been developed and need to be 
researched, developed, enhanced and expanded. Murphy and Mitchell (1998) developed 
a three-component convention to provide a text-based alternative to the non-verbal cues 
in traditional counseling. Technique 1 is called "emotional bracketing". In the text of an 
email or other text-based communication, the writer puts the emotional tone of his or her 
thought in parentheses (p. 24). For example, a therapist may be concerned because the 
client mentioned his car was stolen then skipped without elaboration to another topic. 
The therapist might write. Let me interrupt here and return to your mention of your car 
being stolen (concern, puzzled). What have you had to do as a result . . . police, public 
transportation, . . .? I know you frequently have to take your aunt to doctors' 
appointment (proud of your commitment)? How are you coping (knowing you have)? 

The second tool or technique Mitchell and Murphy developed is called 

alternatively "textual visualization" or "descriptive immediacy". They provided the 

following example. 

"If you were standing beside me as I write this, Tanya, 
you would notice me stopping often, falling back against 
the back of my chair saying "that's incredible" to myself. 
Your recent successes against guilt are so wonderful that 
even now I find myself (right now!) Stopping in the 
middle of the sentence, my hands towards the computer 
screen, my mouth wide open as if to say "this is amazing. 
How did she defeat guilt?" (p .24)." 

Third, Mitchell and Murphy encouraged the conscious, deliberate use of literary 
tools simile, allegory, metaphor, poetry, story telling, and mythology commonly used in 
face-to-face therapy. These techniques have expanded the repertoire available to 
therapists well beyond the effective but static emoticon or smiley, for expressing 



28 

emotional context, for making content explicit and for making the here-and-now process 
comments so vital to counseling, in text talk. 

Another equally interesting concept is "hyper-personalization". Walther (1996) 
introduced the concept of a reinforcing feedback loop, which he called an intensification 
loop. He suggested that a person can project his or her idealized self into the 
communication and be reinforced for that idealized self, increasing the realization of that 
ideal in their daily off computer life via ego strengthening. He also suggests that when 
communicators do not have to pay attention to social cues they pay more attention to the 
text and its meaning. He did not, however, discuss whether this enhances or distracts 
from therapy. 

Patterson (2000) and Riemer-Reiss (2000) each reviewed Internet rehabilitation 
service delivery and concluded that the Internet offers accessibility, immediacy, 
advocacy, and competency for rehabilitation counselors and their consumers and also 
challenges and ethical considerations. Patterson mentioned the availability of vocational 
information, Department of Labor Statistics, job banks, placement resources, medical 
information, free or inexpensive assessment tool (e.g., Keirsey Type Indicator, Career 
Interest Game, Career Key, Birkman Method Career Style Summary and the Self 
Directed Search), support groups and continuing education. Patterson advised 
"judicious" use to complement the work of human interaction. 
Mutual trust or trustworthiness 

Trustworthiness, consisting of dependability, reliability and honesty, is essential 
to a good counseling relationship (Ainesworth 1995). These mirror the qualities Roger's 
(1957) included in what he considered necessary and sufficient conditions for person 
centered therapy to be effective. Trustworthiness, on the Internet has been researched by 



29 

Cheskin Research and Studio Archetype/Sapient (1999 because of it is vital component in 
ecommerce. Web site and email security were discussed in length below because 
cyberspace is mysterious to many users and because privacy, confidentiality and 
credibility are essential factors for instilling a sense of trust. 
Intimacy 

Intimacy, in a clinical sense, has to do with the amount of self-disclosure exists in 
a relationship (Robson & Robson 1998). As a relationship develops and matures, the 
amount of self-disclosure increases and expands. For counseling, self-disclosure is 
essential. Self-disclosure must be monitored. Too much self disclosure, prior to 
sufficient development of presence and trust, can rupture a budding relationship just as 
too little disclosure later in a relationship can regulate it to distant, formal, casual and 
atrophying because it lacks depth and richness. 

Social presence, mutual trust and adequate and appropriate intimacy or self 
disclosure exist on the Internet and are richly communicated through email, chat rooms, 
bulletin boards, and multi- user domains. This research (Sproull 1997, Robson & Robson 
1998, Barak 1999, Suler 1999, Mantovani 2001, Stanley 2001) is fundamental because 
without these factors, counseling could not realistically expect to develop a human 
relationship and personal bond needed for a therapeutic alliance to move the therapy to a 
satisfactory outcome. 

Internet Counseling Issues 
Website Security 

Counseling room security is a significant concern especially in university teaching 
labs and public clinics where sound readily passes through the walls. The problem of 
"eavesdropping" escalates on the Internet. Electronic transmissions are most vulnerable 



30 

to security breaches at their origin and at their destination. In transit, the message 
consists of binary code that has been broken into several "packets" each of which travels 
the Internet independent of the other. At the destination, they are reassembled and 
checked for completeness. 

Security should be applied at each end point where the message is complete and 
readable but the counselor can only control his or her end of the communication. It 
seems obvious that therapy should not be conducted from the client's employer's 
computer or from a public computer (library, computer cafe, etc.). Ironically, these sites 
may be the client's only Internet access. Law and legal intervention cannot secure 
wireless connections to the Internet. Hardwired cable modems or DSL cables are also at 
risk because they establish a permanent address for the computer access rather than a new 
one with each dial up making the connect susceptible to deliberate attack. Dial up 
connections are vulnerable to disruption of service. The client and therapist each have to 
be responsible for common sense and security on their respected ends of the transmission. 

Grohol (2001), who credits himself with creating the term "e-therapy", claims that 
e-therapy is more confidential and secure than traditional psychotherapy citing thin 
walled clinics, and patient charts available to clerical personnel as evidence of lack of 
security in a traditional office or clinic. Grohol does have a point to the extent that unless 
a therapist sound proofs his or her therapy room, encrypts all telephone calls to 
patients/clients, and checks the office regularly for surveillance devices, does his or her 
own transcription, copying and filing, and so forth, most Internet psychotherapy is as 
secure as its face-to-face counterpart. Workers Compensation required that all case notes 
relevant to the injury be copied and submitted with the request for payment. How secure 



31 

is that? Physical security is the most crucial place to insure office or Internet privacy and 
confidentiality. (Smith 1997) In recent spy scandals, the main issues involved missing 
disks, missing laptop computers, and missing hard drives, not Internet or Intranet 
security. 

Encryption (Smith, 1997) offers the second mode of protecting Internet privacy 
but has no application if one uses a cell phone or wireless Internet connection (encryption 
is legally defined as a munitions in the USA and 40 other countries). Ironically, it is the 
geographically remote who rely on wireless communication. The average user can 
connect to the Internet in one of three ways. Dial-up connections use regular telephone 
lines. In remote areas, some telephone lines still use analog (rotary, pulse) system and 
cannot dial up an Internet Service Provider (ISP). Television cables offer another way to 
connect to the Internet, but cable television is likewise not economically feasible for the 
companies in remote areas and therefore not available to one of the most under served 
populations. Dish satellite is available in remote areas but because it is wireless, it cannot 
be legally encrypted. Most high-speed Internet connections rely on microwave towers 
and as a result are wireless even when offered by the local telephone carriers. Cable 
high-speed Internet connections are probably the only DSL connections that use physical 
wire. Internet security is a matter of therapist knowledge and proper application of both 
hard ware and software solutions (Smith, 1997). T-4 lines are the most secure, most 
expensive, and least available to the average therapist. Furthermore, even if the therapist 
has a secure high-speed connection, the actual communication between a therapist and 
client can only proceed at the rate of the slower system. 



32 

The issues for email, chat, and bulletin board security include authentication, non- 
repudiation, public key distribution, and mailing list handling (Smith 1997, p. 287-296). 
Authentication asks "who wrote the message" did the therapist write the message the 
client receives, did the client write the message the therapist received. Non-repudiation is 
important in legal matters, commonly business contracts but, for the therapist and client 
in potential lawsuits ~ divorce, custody, criminal, and malpractice. Public keys are 
passwords and other encryption devices use to allow discretionary access to information. 
Mailing list, (e.g., listserv, USELIST) are difficult to encrypt because the decryption must 
be specific for each receiver. 

Cryptography and secret codes has a long history in government, intelligence and 
military use but equally if not more importantly in business and commerce. Modern 
cryptography has been spurred by the business and commercial needs of the Internet and 
by major advances in modern mathematics that provides the means to develop nearly 
indecipherable code algorithms. The therapeutic community is rightly concerned about 
privacy and confidentiality. However, "hacking" or breaking into a properly secured 
computer system, is actually very difficult, rare and targets valuable and marketable sites. 
With this caveat, the therapist is wise to encrypt his or her site for the protection of the 
therapist/client communication and use a third party secure payment company, which 
specializes in the coding/decoding in monetary transactions. This protects both the 
therapist and the client from external credit card fraud, exploitation, and subterfuge. It is 
the most complex, expensive and restrictive form of encoding. Companies exist to 
handle financial transactions because the ordinary transactions of many businesses are 
not worth the time and trouble required to intercept or forge them. It is a much better 



33 

business strategy to hire out secure credit card processing than incurring the expense and 
risk of doing it in-house. 

Mitchell and Murphy (1998) recommend that all e-mail be encrypted but agree 
that it may be too anxiety producing to ask of a client seeking professional help to acquire 
and learn to use an encryption program (p. 52). E-mail can be encrypted with free or 
inexpensive software but it only works if it is installed and used properly. PGP (Pretty 
Good Privacy) encrypts both e-mail and files for a one-time cost. The software "plugs 
in" to common email programs such as Endora or MS Outlook, to encrypt files, disks and 
existing email on a hard disk. ZixMail is a secure email application, which downloads 
free but requires $1 per month payment. Zip-Lip and HushMail are both free secure web 
messaging services. Messages remain on the server so they cannot be intercepted. 
Nothing is stored on the clients' computer or the therapists' computer (HON, 1995). The 
major concern about the use of encryption software is not the quality and usefulness of 
the software, but the misuse or inappropriate use of the software (Smith, 1997). 

The electronic security issues, technological failures and access have as long a 
history of research and development as do research on therapy relationships and outcome 
efficacy (Wright & Greengrass 1987). Electronic security is directly related to ethical 
issues of privacy and confidentiality. While news media seem to frequently report 
breaches of electronic security, a close examination of recent espionage incidences reveal 
that most involve an insider (Lee, Ames, Hansen) who has direct, physical access to the 
hard drive, server, stolen laptop, software, encryption/decryption devices or paper files. 
Virtual Private Network (VPN) is the concept of using private computers (desktop, 



34 

laptop, mainframe or server), firewalls, public servers, the Internet and the client's 
personal computer (Barlow 2001, Fratto 2000). 

Certification authority issue digital signatures after performing background 
checks to assure that the company certified is what it claims to be. The personal digital 
signature certificate verifies that the user is who he or she claims to be. Loss or misuse of 
a digital signature certificate has serious consequences, comparable to loss or misuse of a 
passport. A digital signature is also analogous to a business or occupational license and 
bonding. 
Legal Considerations 

State licensure and states rights are the key legal issues in Internet psychotherapy. 
Federal and state laws regulate Telemedicine (Congress 1997, HCFA 1996, HCFA 1999). 
Interestingly, both California and Minnesota have passed laws allowing reimbursement 
for telehealth services (Jones 1996a, Jones 1996b). California (Maheu 2001) has also 
passed an Internet psychotherapy law restricting practice to in-state clients. Case 
Managers, rehabilitation counselors, and nationally certified counselors in states without 
licensure may be relatively safe practicing under their national certification. There is 
ultimately no way to know if the person with whom the therapist is communicating is 
physically located in a state or nation where the therapist has a license or certification. 
As a result, much of the experimental research on Internet psychotherapy is being 
conducted in Israel (Barak 1999, Barak & Wander-Schwartz 1999), Australia (Reid 1994, 
Smith 1997), and Canada (Murphy & Mitchell 1998, Mitchell & Murphy 1998). 

Dunaway (2000) discusses both jurisdiction and malpractice insurance issues 
"The potential for out-jurisdiction counseling is another hurdle faced by e-therapy. State 
licenses restrict providers to practice within a state, but patients on the Internet can reside 



35 

anywhere. This is an unsettled area, so it is smart to take a conservative approach until 
further guidelines are developed." She advised, "generally speaking, unless there is a 
specific disclaimer in the insurance policy, the carrier would have difficulty denying 
coverage for malpractice claims for work within the scope of mental health treatment by 
a licensed psychiatrist." Therefore, a licensed professional may be covered for liability 
while practicing on the Internet but geographic scope of practice area is a concern. 
Grohol however points out, sadly, that licensing boards are infamously inactive in 
pursuing complaints and taking action against licensed professions. His advice is to 
practice within professional ethical guidelines and within one's expertise and let case law 
evolve (Grohol 1999a). 
Modalities 
Telehealth/Telemedicine 

The American government and military interest in the Internet included all 
aspects of defense including the health and care of personnel in remote areas. 
Telehealth/ Telemedicine is the branch of Internet use and research that provides 
electronic healthcare to military and civilian populations who lack readily available 
geographic access to medical care. 
E-mail 

Therapy via e-mail is currently the most widely used form of Internet mental 
health service outside Telehealth/Telemedicine, and the most accessible to clients and 
therapists. E-mail was an after thought of Internet developers who found it convenient to 
communicate with one another involved in a complex project design. It requires minimal 
bandwidth and can be accessed with an "appliance" for those who cannot afford a 
computer. E-mail service can be obtained from several free sources. 



36 

Murphy and Mitchell (1998) developed techniques described above and wrote 
about their qualitative observations from conducting therap-e-mail on their web site 
http : //wwwtherapylnternet . ca . They required potential clients to complete and return an 
on line form called the Virtually Solve It worksheet, which can be completed offline. 
They believed that the permanent record of email makes consultation and supervision 
easier. A response can be reviewed by the supervisor, consultant or peer prior to being 
sent to the client (p. 26). The permanent potential of email encourages the therapist to be 
thoughtful and behave in an ethical manner (p. 27). Clients found that filling out the VSI 
and writing out their interactions with the therapist externalized their problems making 
them easier to confront and resolve (p. 27). Repeated efforts to obtain this form were 
unsuccessful, so it appears no longer to be a viable web service, however GrohoFs site is 
active and has pre-therapy form at http://psychcentral.com. 

Mitchell and Murphy recommended that further research should be conducted to 
study the impact and effectiveness of their techniques (emotion bracketing and textual 
visualization (descriptive immediacy); application of narrative and solution focused 
therapy in face-to-face and electronic therapy; impact of writing itself in the therapeutic 
process; and pre-treatment effect of writing to the therapist (e.g., using the VSI)( p. 30) 
Chat/Conferencing 

Suler (1997) describes text talk as austere because it lacks voice, facial 
expression, body language and visual/spatial environment. While some may find this 
disorienting, he suggested that for many, text-talk is a more direct, intimate mind-to-mind 
communications approximating an internal dialogue. In his study, Suler analyzed 
"many megabytes" of saved logs exploring the concerns that the absence of visual and 
auditory cues confuse users, and lead to painful misunderstanding. He identified 



37 

phenomena of text-based conversation. There is often a lag in live messages due to 
Internet connection speed. He called these out-of-syn occurrences, temporal hiccups. 
This can seem similar to talking over another person in face-to-face conversation. The 
Internet therapist will need to determine whether he or she is viewing a temporal hiccup 
or an interpersonal issue. Most chat modes providers, including AOL and WEBCT (used 
in this study), allow for only a line at a time text entry (plus cut and paste for large pieces 
of text). Correspondents don't actually see what the other is typing until it is published 
using the enter key. ICQ in live mode however allows for a more natural ongoing 
conversation limited only by the speed/skill of the typist. Writing is live rather than 
written then sent. There is software that allows one speaker to complete a lengthy 
thought before the next message posts and was used extensively in Taylor's AOL Dream 
Group Therapy. 

Suler (1997) developed a convention of "listening". When one person was clearly 
caught mid-sentence or mid-thought by the limitations of the program, others "need to sit 
back in a 'listener' mode. Some users will even type "listening to Joe" to indicate this 
posture to others (p. 5)". He describes "staccato speak" as a joking around or playful 
exchange, a group "free for all ( p. 6)." His illustrations are reminiscent of the "Fireside 
5" or "Monty Python" comedy routines ( p. 6). Suler includes acronyms (e.g., brb for be 
right back) under this category but this researcher tends to see acronyms as more similar 
to emoticons, emotion bracketing and other text talk enhancement. The occurrence of 
"staccato speak" (minus acronyms) in psychotherapy could signal anxiety or avoidance 
of painful emotions. 



38 

Barak et al (1999) conducted one of the only empirical studies reported. He and 

his team chose synchronic chat groups for their research because e-mail, the most 

common form of Internet therapy, 

"lacks a key feature of human interpersonal 
communication characterized by spontaneity, authenticity, 
immediacy and directness. This feature is directly related 
to the commonly accepted and generally appreciated 
therapeutic factor of here and now. Numerous schools of 
psychotherapy argued that this immediacy factor may be 
responsible to a great degree for dramatic therapeutic 
developments. In addition, defense mechanisms or 
cognitive distortions (depending on the school of therapy) 
are less, likely to take place in a "here and now" therapeutic 
situation, (p. 1)" 

In this study of brief Internet Chat room group therapy, Barak, recruited 15 
students from several Israeli universities and community colleges. Six participants (three 
men, three women) were assigned to the Internet condition and nine students (three men 
and six women) were assigned to a traditional face-to-face group therapy. Both groups 
were led by experienced, female therapists and were brief, dynamically oriented. One 
therapist conducted the Internet group while the other conducted the face-to-face group 
therapy. The Internet condition was conducted in a JavaScript, password protected chat 
room for seven, ninety-minute sessions. The face-to-face group met on the campus of the 
University of Haifa. The dependent measures were Measure of Therapy Impact: Self- 
Esteem, Social Relationship, and Well-being. Each scale was a 25 item Likert-like scale 
but Barak does not cite the source of these measures Moose (1981) developed the group 
process measure, a Likert-like evaluation questionnaire designed to elicit opinions about 
the Internet group therapy experience. Because of the small number of participants in 



39 

this study, the data were evaluated qualitatively by analyzing chat room transcripts in 
addition to reviewing the results of the dependent measures. 

Results indicated that participants exhibited positive support, personal disclosures, 
interpersonal sensitively and group cohesiveness. No comparison with the face-to-face 
group was reported. Recommendations for further research include a study of 
preparation for therapist for Internet therapy, and rules by which such groups should 
operate (Barak & Wander-Schwartz, 1999). 

Multi-modal 

Colon (1994), a prominent social worker, conducted one of the first studies of 
Internet psychotherapy. She conducted a three-month study with eight participants using 
email, chat and bulletin board. Participants were recruited and screening Internet from 
ECHO subscribers. Participants were screened, refrained from in person contact with one 
another or Colon, posted/participated actively at least three times a week and participated 
for three months. Colon's training was psychodynamic and so were her Internet groups. 
Her primary concern about the experiment Internet groups was the absence of non-verbal 
cues. (p. 9). She concluded "In Internet therapy, and perhaps in the psychoanalytic 
session, language is action. Nothing "happens" Internet, or for all intents and purposes, 
in therapy. There is no way to quantify what happens in an Internet group. And yet lives 
can change." 

Phillips (1996) qualitatively compared four groups within which she participated, 
an Internet service Adult Children Of Alcoholics (ACOA) chat group, an Internet service 
ACOA email list, an Internet ACOA email list and an ACOA chat group she created on 
the Internet service. None of these groups appear to be formal groups with regular 
attendance, ground rules and on going interaction as defined by Yalom (1995) whom 



40 

Phillips cites extensively. She reported that each group was roughly organized along the 
12-step philosophy. Her discussion indicated that she was a participant in the first three 
groups rather than a researcher or group leader. She briefly touches on private 
conversations (IM), cross talk, advice giving, and anonymity as assets of Internet groups 
but there is little research in group therapy to support these as constructive, which she 
acknowledged, but saw as a positive difference between in person and on line groups. 

Suler (2000) complied a list often issues to consider in developing understanding 
in Internet groups and communities. These are general considerations about the 
uniqueness of the Internet rather than group process constructs. 
Unidirectional Information Only 

Many Internet using therapists are cautiously waiting for legal issues to be 
resolved and are providing only information, advice, or recommendations, but not 
psychotherapy. Grohol's forced and constrained definition of e-therapy demonstrates this 
caution (Grohol 1999b, Grohol 2001), while he is, paradoxically, one of the most 
outspoken researchers defending the legality of Internet work (Grohol 1999a). 
Unidirectional information is generally health related articles, electronic journals, and 
patient information sheets (e.g., WebMD.com, MayoHealth.org). 

Guidelines for Ethical Practice of Internet Counseling 

The need for ethical guidelines to direct the development of Internet 
psychotherapy services was recognized by all major mental health organizations almost 
as soon as the Internet became commercial. The Health on the Net Foundation published 
HON Code of Conduct for Medical and Health Websites (HON 1995). Two years later, 
in 1997, the National Board of Certified Counselors published Standards for Ethical 
Internet Counseling ; and the American Psychological Association published Services by 



41 

Telephone. Teleconferencing, and Internet: A statement by the ethics committee of the 
American Psychological Association ). In 1998 the American Medical Informatics 
Association published Guidelines for the Clinical Use of Electronic Mail with Patients . 
The American Counseling Association published Ethical Standards for Internet 
Counseling in 1999. The International Society for Mental Health Internet and the 
Internet Health Coalition each published their standards in 2000. In 2001, the American 
Psychiatric Association published American Psychiatric Association principles for 
medical ethics with annotation especially applicable to psychiatry . 

In a pilot study, Mitchell and Murphy (1998) examined the email therapeutic 
relationship with one client who had engaged in over 100 transactions with the therapists. 
In 1995, the researchers had set up a pilot counseling site on the local computer bulletin 
board service. They limited access to counseling services to two thousand members. 
The services offered were the Virtually Solve It worksheet (VSI) an Internet form design 
to help the potential client explore and externalize the problem. They introduced therap- 
e-mail and Ask PATtYQ , which stood for Professional Answer To Your Question. In 
1998 they interviewed the one client chosen for qualitative response to issues being 
debated by the National Board of Certified Counselors committee on WebCounseling 
ethics - security issues, physical absence, emergency situations, technological failure, 
therapeutic relationship/efficacy and access. 
Credential Validating Referral Sites 

Reliability, credibility and freedom have been the core values of Internet 
developers almost since its inception and certainly, since, it became available to the 
public. Switzerland is home to two of the primary Internet regulatory bodies, the WWW 
Consortium and Health On the Net Foundation http://www.hon.ch/ ~ @HON. The W3 



42 

Consortium sets voluntary but fairly universal technical standards used in HTML, 
JavaScript and other development and implementation design tools. @HON, which 
organized in 1997, sets standards for health and health related web activity. @HON, has 
a strict, enforced code of conduct in seventeen languages, requiring trained and qualified 
professionals, support not replacement of traditional care, confidentiality, appropriate 
credit to source materials, justifiability of products or services, transparent authorship, 
transparent sponsorship, and honesty in advertising and editorial policy. @HON enforces 
compliance in several innovative ways. The @HON logo, which is displayed on certified 
web sites, is "active" or "live". When a web site visitor mouses-over the @HON logo it 
will link to the @HONcode web site. Non-certified web site designers can copy the logo 
to their web site but cannot copy the active link. Web users are aggressively encouraged 
to report any non-active links for @HON team action. The @HON team uses the active 
link to perform random web site checks. To earn the right to use the @HON active link 
logo, the web site designer must complete a detailed application and submit to a @HON 
team examination of the Web site. The applicant must make changes required to come 
into compliance with HONcode (HON 1995). @HON is recommended by such 
prestigious American medical organizations as the Mayo Clinic "When you visit a health 
Web site, look for a logo from the Health on the Net (HON) Foundations. Sites that 
display this logo agree to abide by the HON Code of conduct. Some sites may choose 
instead to publish a statement explicitly affirming that they are in compliance with the 
HON Code of Conduct (Edwards, 2000)." 

The International Society for Mental Health Internet http://ismho.org/ , and 
WebPsych Partnership sponsored by ISMHO http://www.ismho.org/webpsych/ are the 






43 

major American based mental health Internet research, development and self regulating 
organization. Membership and use of the ISMHO logo on a web site is open to any one, 
professional, consumer or other, who is interested in the development of mental health 
resources on the Internet, for a modest annual membership fee. There is no site 
evaluation or monitoring such as @HON uses. The goals of these organizations, 
however, are not necessarily congruent with those of the professional organizations. For 
example, the goal of the WebPsych Partnership is "to ensure a high quality of Members' 
sites and reduce unnecessary competition and harmful in-fighting." In fairness, it does 
seem to be focused on promotion of web sites and accuracy of web sites rather than 
interaction with clients or other persons seeking mental health information. 

Ainesworth's web site, http://www.metanoia.org, was organized in 1995 and 
remains one of the primary resources for information about mental health resources, 
counselor referral and information. She is a consumer report organization. She 
adamantly does not hire therapist or market services. Her listings are free, but the e- 
therapist must meet criteria that includes — having a web site which she evaluated with 
@HON standards, communicating personally with individuals, personalizing help to 
these individuals, and communicating with individuals through the Internet. She will not 
list any "sites where services are not offered by a credentialed professional 
psychotherapist." 

There is a profusion of sites and listings that do not require professional criteria 
for inclusion, but do have some criteria. Mental Health Resource with Leonard Holmes 
Ph.D. purports to be "your guide to over 700 sites"; however, these sites include related 
professions such as law and unrelated topics such as aliens. The criteria to list with this 



44 

site indicated that a web site "should not be used to advocate or promote the following: 
any illegal activity, activities that support or espouse non consensual and/or extreme 
violence or sexual aggressiveness toward another individual or group for any reason, 
activities that support or espouse hatred towards another individual or groups based on 
any criteria and activities and input from individual that violate our inclusive standards 
http://mentalhealth.about.com ." While these are laudable criteria, they fall short of 
mental health professional practice criteria. 

Clinician's Yellow Pages http://mentalhelp.net/mhn/yeHowpages/ ; Who's Who in 
Mental Health on the Web http://idealist.com/wwmhw/; Find-a-Therapist; and 1-800- 
Therapist; list web site for an annual fee, without evaluation or monitoring, similar to a 
listing in the Yellow Pages of a telephone directory. 

Basically, a psychotherapist practicing on the Internet must establish all the same 
security, authenticity, and grievance procedures as the psychotherapist seeing clients in a 
physical office. A physical office has a pleasant, soothing decor, locks on the doors, 
security system, secure location and procedures for charts, requests for notes and so forth. 
In physical office, a therapist must display, at minimum, the occupational license and the 
professional license to demonstrate authenticity and grievance resources. The virtual 
office needs an effective web site that is uncluttered, appealing, and easy to navigate. 
There must be firewall(s) protecting the therapist's computer system, SSL across the 
network and easy instructions for client firewalls (locks on the doors). Authority to 
practice is demonstrated by posting live logos (i.e. licenses) for security (e.g., Verisign) 
and credentials (e.g., @HON). Live logos are linked to the company and the client can 
instantly verify the therapist's legitimacy to the extent of each authoritative body's 



45 

responsibilities. No one denies that these technologies are cumbersome and may well 
cause therapists to think twice about practicing on the Internet or incline some therapists 
to practice without adequate safety precautions. 
Advantages of Internet Counseling 

The perceived advantages of Internet Counseling are it's immediacy, availability, 
anonymity, and economics (Brown & Walz 2000, Fink 1999, Grohol 1999b, Grohol 
2001, King & Moreggi 1998, Patterson 2000, Stubbs 2000). Internet access is 
immediate, any day of the week, any time of day, any where in the world. One does not 
have to wait for business hours or for an appointment. The Internet users in search of 
information, companionship, and advice to get through a sleepless night, pain, or spasms 
can readily find help in a chat room, bulletin board or informative web site. The Internet 
is available in many remote geographic areas where users do not have access to 
therapists. It is available to situationally remote users include home bound care-givers, 
the elderly, persons with disabilities, and those who would be at employment or social 
risk from seeking counseling. The Internet can be anonymous. Personal information 
(age, gender, ethnicity, physical condition) can be disguised. Web counseling is 
considerably less expensive than traditional face-to-face counseling. The overhead of 
maintaining a web counseling site is much less than that of renting office space, 
maintaining a staff, occupational license, furniture and equipment, the myriad of taxes, 
and other "cost of doing business" in the traditional setting. Owners of the PsychOptions 
site http://www.psychoptions.com/raters_&_types_of_services.htm , for example, lists 
the following charges: One question/one problem $25; One e-consultation/first on-going 
session $50; On-going session $35; Telephone session $50 for 50 minutes. The one 
question, e-consultation and on going sessions are all conducted by email. The 



46 

PsychOptions site offers a sliding scale "If you have extenuating circumstances and/or 
are over 65+ and/or on a fixed income then you may contact PsychOptions to request an 
adjustment and explain the reason why." 
Disadvantages of Internet Counseling 

Internet counseling is a double-edged sword. The disadvantages of Internet 
counseling can be the same as the advantages ~ immediacy, reliability and validity of 
information, security (e.g., privacy and confidentiality), anonymity, abandonment, 
physical absence, ethics, legality, and security (Grohol 1996, Storm & Moreggi 1998, 
Oravec 2000). While a potential client may be assured of a response within 48 hours 
while a non-crises office client may have to wait a week or two for a first appointment, 
the quality of that first contact may be no more valuable than the first phone calls to a 
physical office and responses appropriately provided by trained office staff. The 
credentials of the Internet counselor may be as valid as those of the office counselor; 
however, it is generally more difficult to verify those credentials as demonstrated above 
in the extensive discussion of web security. In a traditional office the client can examine 
see the professional license and the business license, both of which are required by law 
(at least in Florida) to be prominently displayed. The local Better Business Bureau and 
Chamber of Commerce can both be contacted to check the counselor's business history 
and can offer recourse if problems arise. 

As discussed above the web is developing comparable resources in @HON and 
Metanioa.com, however they are not well known. Furthermore, in a physical site, the 
client has recourse if credit card charges, personal checks and cash payments are 
mishandled. Again the Internet offers security but many sites promise security (e.g., 
affordablewellness.com) when in fact they are not secure. Buyer beware is never more 



47 

true than in the Internet environment. PayPal.com acquired by Amazon.com in July 2002 
offers some of the same financial recourse as services continue to evolve in the credit 
card industry as e-commerce grows. Unless the URL begins with https (hypertext 
transfer protocol secured), the site is not secure. Unless there is a small padlock icon on 
the status bar of Internet Explorer or Netscape, the site is not secure. Again, many 
consumers, especially in a time of stress or crises precipitating contact with a counselor, 
may not be aware of these Internet conventions. To avoid the expense of a secured site, 
many small merchants ask that credit card numbers be emailed to the site. Email can be 
secure but again, if it is, there is evidence of that security that clients are unlike to know 
or consider in a time of distress. Does Internet counseling provide privacy and 
confidentiality both in personal information and financial information? It can, but many 
sites do not. 

There is often legitimate concern in physical counseling rooms about thin walls, 
crowded waiting rooms, and non-counseling staff access to chart notes. There are, 
however, analogous problems in a cyber counseling room - the client's own family or co 
workers may have access to the screen as the client "talks" with the counselor or to the 
records in the computer. A spouse seeking a contested divorce, a vindictive co-worker 
and other persons with agendas harmful to the client may be able to print off logs of the 
sessions, emails, or bulletin board postings. Clients, computer end users, may or may not 
be aware of what is recorded in the computer program itself. A client can conscientiously 
protect his or her email correspondences, and yet never know that the chat session is 
automatically being saved by the computer software. The client's own associates may 
have more access to the very information that the client needs to have secure from others. 



48 

Another disadvantage is face validity on the Internet. A well-designed site may 
have powerful face validity that speaks volumes for the competence of the web designer 
but say nothing about the credentials and skills of the counselor. With a population 
accustomed to visual pleasure from screens - television, movie, electronic games, and 
computer monitors, the design may allow totally unqualified, perhaps even harmful 
"counselors" to garner large "practices". What you see, may not be what you get. 

Anonymity, abandonment, and physical absence are closely related. The client 
and the therapist for that matter can disguise his or her identity on the Internet. This 
reality needs to be built into Internet counseling theory as the modality evolves beyond 
applying traditional modes to the new media. The client could also disguise his or her 
identity in person although it is more difficult if payment involves insurance policies or 
credit cards. Abandonment is a serious risk on the Internet, while it less likely to occur in 
a physical practice setting. Traditional clients may feel abandoned when their treatment 
is completed, when they are referred to another mental health care provider when these 
issues required different skills or training, or, in a clinic setting where the counselor tum 
over may be high; however physical sites rarely "just disappear" the way web-sites do. 
Some argue that no interpersonal bond in the cyberspace can replace actual physical 
presences (Plant, 1996). 

Cognitive Behavioral Counseling Models 

Cybercounseling is not limited to one or a few theories or therapeutic models of 
counseling. Researchers have studied family (Oravec 2000), self help (Storm & Moreggi 
1998), group (Barak & Wander-Schwartz 1999, Colon 1994, Suler 2000), and brief 
cognitive (Edelstein 1996, Palmer & Ellis 1995, Ellis 1996), therapies conducted in 
cyberspace. This study, however, will apply the brief cognitive behavior therapy model 



49 

because it is best suited to the participant population, personal growth issue-focus and 
alliance development. As such it provides a model appropriate for 3-session, personal 
growth focused study conditions. 
Cognitive Behavior Therapy 

Cognitive Behavior therapy grew out of the work of social learning theorists 
including Lewin, Bandura and Lazarus. Prominent researchers in this important area of 
theory and therapy include Ellis, Miechenbaum, Beck, Burns, Marks, and Rush. 
Miechenbaum (p. 179-198) describes the process of therapy as involving three mental 
constructs he calls cognitive events, cognitive processes, and cognitive structures. His 
theory links these cognitive constructs to emotion, behavior and logical and natural 
consequences of those behaviors. Cognitive events are conscious, identifiable and readily 
retrieved thoughts, images and feelings. They include appraisals, expectations, 
attributions, self statements, automatic thought and internal dialogue. The person 
experiences them as spontaneous, and rarely questions them. These events occur when an 
individual is trouble shooting a problem, uncertain about an action or choice, and when a 
routine behavior is blocked requiring an alternative or creative solution. Cognitive 
processes are the mental processes by which we acquire information, store it in short 
term and long term memory, appraise information, filter it, and recall it. Meichenbaum 
identifies three cognitive processes that lead to emotional distress - confirmatory bias, 
mental heuristics and metacognitions. Confirmatory bias is pre conceived notions or 
ideas that function as fact. Mental heuristics in the habit of selecting experiences or 
information that confirm pre-conceived biases. Meta cognition is the ability, knowledge 
or skills to be aware of and control ones own cognitive processes. The process and goal 
of cognitive behavior therapy is to educate the client in recognizing his or her cognitive 



50 

events, cognitive processes and meta cognition. Cognitive templates or schemas are 
identified and the client is enabled to change those templates that no longer function in 
his or her best interest. Meichenbaum encourages the client to be his or her own "folk" 
scientist and assigns "experiments" to develop needed skills. He encourages therapists to 
use specific examples to identify faulty logic "We have found that people often make 
certain kinds of errors in the way they look at situations and that these errors in thinking 
may contribute to arriving at premature or incorrect conclusions. It's natural to readily 
come to such conclusions without even noticing them (p. 193)." Logical errors include 
all or nothing thinking, seeing possibilities as certainties, dichotomous thinking, 
personalization and self blame for negative events, and over generalization. Because this 
theory and therapy relies on homework and experimentation by the client to reach his or 
her own conclusion, that affect change, it is adaptive to an Internet Counseling 
environment. 

Gabriel & Holden (lecture reported in Laszlo 1999) developed an Internet 
protocol for cognitive behavioral therapy, that looked at theme patterns in text based 
sessions. They sough patterns of over generalization as indicated by the use of polar 
adjective, excessive self attribution of responsibility, minimizing or maximizing 
significant issues, and focusing on negatives (p. 296-297). There does not appear to be 
further information on their theory or research but it is intuitively practical. 

Ellis developed Rational Emotive Therapy (REBT) in 1955 and changed the name 
of this theory and method to Rational Emotive Behavior Therapy in 1993 to include the 
Behavioral component of change, which had always been present in his theory (Ellis 
1998). He posited emotional and behavioral problems have their source in faulty 



51 



thinking or irrational beliefs. His ABC model has grown alphabetically over time but still 
focuses on an Activating event, some event at work, home, or interpersonally that triggers 
the emotional crises or Consequences. The client experiences the Consequences with or 
without being aware to the triggering event and generally without being aware to the 
irrational, rigid belief that connects a triggering event to the emotional or behavioral 
consequence. In REBT, the irrational belief is Disputed using cognitive skills introduced 
by the therapist but practiced in homework by the client. The outcome is Effective and 
Efficient responses to would be Activating events. Ellis identified eleven irrational 
beliefs that cause the gamut of emotional problems. 

Some of the websites established by founding CBT therapists are located at : 
Aaron Beck, M.D. — http://www.beckinstitute.org ; David Burns, Ph.D. - 
http://feelinggood.com ; Albert Ellis, M.D. - Http ://www. rebt . org ; Isaac Marks, M.D., - 
http://www.thisiswiltshire.co.uk/ ; Donald Meichenbaum Ph.D. - 
http ://www. arts. uwaterloo. ca ; and A. John Rush, M.D. — 
http://www3.utsouthwestern.edu/psychiatry/facbios/rush.htm/ 
Brief Cognitive Behavior Therapy 

Ellis (1996), Beck (1979) Burns and Meichenbaum (2000) have each researched 
and developed brief cognitive behavior therapy protocol some of which are as brief as 
one session maximum benefit. In a World Counseling Network forum Ellis (1998) 
describes REBT as "designed originally because psychoanalysis and most other forms of 
therapy were very long winded. So I tried to devise a system that would understand the 
core beliefs, the core irrational beliefs of the clients very quickly and help them to get to 
work to dispute them and debate them in a short period of time. So in a sense REBT was 
on to the few therapies designed to be brief (p.2)." In reply to a question about efficacy 



52 

of short term therapy, Ellis mentioned that "at least 1000 empirical studies. . tend to 
show that short term therapy at least when it is done with CT or REBT definitely is as 
effective or more effective than other kinds of therapy and more effective than the 
therapy that is given to control groups (p. 4)." He further cautioned White, de Shazer, 
Watzlawick and other brief therapy authors that they "had better not use the generic term 
'brief therapy' to imply that they are the only form of brief therapy. 

Ellis (Palmer & Ellis 1995) was trained in psychoanalytical therapy but realized 
that it takes "a fairly long time to get people to free-associate, analyze their dream and go 
over and over their childhood and later historical material." He describes his early work 
as psychoanalytically oriented as opposed to classic psychoanalysis. "I found out, to my 
surprise ...that it was better, got better result than classical analysis... you quite quickly 
get their basic history (p. 68-69)." He continued "REBT is intrinsically more efficient 
and briefer. Often during the very first session I can show people the ABCs of distress. . . 
. So REBT is sometimes successfully done in a few sessions (p. 69)." 

In his book on brief therapy, Ellis (1996) affirmed that REBT can be 
accomplished with self help materials including books and cassettes that teach the REBT 
principles Edelstein (1996) advocated three minute REBT sessions applied twice a day 
focused on Ellis' construct of "musty thinking". He demonstrated that one session can be 
sufficient to teach the principles of Rational Emotive Behavioral Therapy and involve the 
client in three-minute techniques. In the forward to Edelstein' s book, Ellis, founder of 
REBT, says "Of course it takes significantly longer than three minutes to dislodge the 
many dysfunctional aspects of a troubled personality. But the clear and simple exercises 
advocated by Dr. Edelstein, exercises, which are totally consistent with my principles of 



53 

Rational Emotive Behavior Therapy, can be practiced in three minute segments, to be 
repeated several times a day." 

Wood (2001) describes the typical CBT length of treatment as brief. "One of the 
major features of CBT is the relatively short time frame required for change to begin. 
Some "brief interventions" were developed using the CBT approach for a one-time, 
several minute session (suitable for application by generalist health workers such as 
nurses and general practitioners). She emphasized that even when these extremely brief 
sessions are not used, CBT rarely requires more than 6-12 months, which would include 
scheduled follow-ups for gain maintenance and stabilization. 

Brief therapy mandates that a therapeutic relationship develop quickly, therefore 
numerous researchers emphasis the need to carefully select high functioning clients who 
have a high level of interpersonal functioning. Seriously-ill clients should be referred for 
long-term therapy where development of the interpersonal relationship can be the focus 
and goal of therapy. (Safran & Muran 1998) These authors recommended that early 
priorities in brief therapy should be to develop the therapeutic bond with warmth, respect 
and genuine interest, reminiscent of Rogers. They offered that the therapeutic rationale, 
the goals and tasks needed to accomplish that goal, should be laid out in the first session. 
They summarize their recommendations metaphorically as "part Marcus Welby and part 
Sherlock Holmes." 

Using Brief Therapy with Undergraduates 
It seems reasonable to assume that most college students are high functioning by 
virtue of meeting admission criteria and remaining in an environment that requires self- 
care and executive functioning. Those who are not high functioning will quickly come to 
the attention of the resident advisors, concerned friends and faculty, or the crisis center 



54 

and be referred for appropriate care or encouraged to return home for care. This is not to 
suggest that college students do not have serious mental health issues and concerns but 
rather that they are most likely to have the personal talents and resources to maintain 
functioning through personal crises and while seeking counseling services available. 
Wilson (1978) addressing common developmental problems of career direction, 
sexuality, belief clarification and separation from parents, went so far as to suggest 
classroom and resident hall intervention would provide cognitive interventions by 
providing problem solving development. Archer and Cooper (1998) , Pinkerton and 
Rockwell (1994) and Steenbarger (1992) have applied the tenets of brief therapy to the 
target population of this study. Although each of these researchers found that there is 
resistant on the part of colleagues to endorse brief therapy, their research and the research 
of others found brief therapy "to be both effective and efficient in campus counseling and 
mental health counseling. 

Luckey (1996) and Christmas (2000) addressed the use of Internet communication 
modalities with college students. Indiana University of Pennsylvania,University Health 
Services (Luckey 1996) used the Internet for communication and data base processing. 
Because this work was written early in the public access to the Internet, its application 
appears to be limited to communicating with and retrieving data from colleagues rather 
than direct student services. However, four years later, Duke University (Christmas 
2000) was using unsecured E-mail (password protection only) with the student body 
population and had established guidelines for interaction with students by email. These 
guidelines specify the exclusion of "sensitive" information that North Carolina state law 
requires a health care provider to present to a client in person (e.g., positive HIV lab 



55 

results, pap smear results, worker's compensation information, and some prescriptions). 
It does not appear that Duke University student health services were providing counseling 
services via the Internet; however the guidelines do not seem to exclude such use as long 
as topics precluded by state law from remote access were not discussed. It is significant 
that Duke University was not using an encrypted site. 
Undergraduate Personal Growth Concerns 

University administrators, entrusted with the education, safety and well-being of 
hundreds of thousands of young adults, many of whom are away from home for the first 
time, have needed to know the kinds of stressors, issues, problems and concerns typically 
manifested on a college campus. Murphy and Archer (1996) identified thirteen academic 
stressors and fifteen personal stressors in a survey of 639 students attending the same 
university as participants in this study. Academic stressors confirmed by a significant 
number of respondents included tests and finals, grades and competition, professors and 
class environment, studying, finances, papers and essays, speaking in class, and others. 
Personal stressors confirmed at a significant level were parental conflicts and 
expectations, finances, interpersonal conflicts, judgment and acceptance by peers, 
personal achievement and goal setting, approaching and meeting other students, general 
adjustments to change, personal appearance, current job, and other. The "other" category 
allowed students to include stressors not mentioned in the survey. The most frequent 
"other" was not getting enough sleep, followed by finding time to get everything done. 
Other statistically significant stressors were family member illness or injury, personal 
health, and pledging. These are the types of issues thought to be appropriate for personal 
growth sessions conducted during this study. The study illustrated that while the rank 
order of problems changed from 1985 to 1993 changed, the categories remained the 






56 



same. The same is assumed to be true between 1993 and 2002; however it recognized 
that the wide spread access to the Internet, the university requirement of personal student 
ownership or ready access to computers, the use of Web based and distant learning and 
the events of 9/1 1/01 may have generated new categories of concern not relevant in 1985 
or 1993 although no such new categories were observed in the present study. 
Individual Information Processing Differences 

Many factors have been demonstrated to influence how individual process 
information such as therapy input and tasks results. Some of these include environmental 
and cultural variables such a race, gender and ethnicity, brain lateralization with emphasis 
on processing information verbally or with images, and personality traits including 
introversion and extraversion. 
Demographic Factors 

The major premise of the huge national investment in Telehealth/Telemedicine is 
that technology provides a method to reach under served populations — women, 
undereducated citizens, rural citizens, Native Americans, citizens with disabilities, and 
citizens of color (HCFA 1996, HCFA 1999). The concern of researchers (Reid 1994, 
Powell 1998) is that the price of technology, and the education and experience required to 
uses these resources may effectively exclude the very populations it is thought to most be 
able to benefit. Powell (1998) found that the majority of Internet therapy users were 
male. 
Learning Style Theory 

Learning style, brain lateralization, and information processing research and 
theory have contributed a substantial body of information indicating that people encode, 
process and retrieve information in distinctly different manners. Two style systems are of 



57 

interest to the present research, academic oriented learning styles and temperament based 
learning styles. Academic learning style theory addresses specific skills and tasks 
generally incorporated into formal pedagogy. Temperament based learning styles affect 
how the individual learns formally or informally by his or her inborn nature and traits. 

Academic Learning Styles 

Of the researched styles, verbal, visual, kinesthetic, group, individual, oral 
expressive, and written expressive (Babich, Burdine, Albright & Randol 1976), the most 
consistently identifiable and validated styles have been visual and verbal (Lazarus 1964, 
Richardson 1969, Richardson 1977, Delaney 1978, Dyckman & Cowan 1978, Akins, 
Hollandsworth, & O'Connell 1982, Akins, Hollandsworth, & Alcorn 1983, Pavio & 
Harshman 1983, Maclnnis & Price 1987). 

Richardson (1969) cites a late 19 th century researcher, Lay, who illustrated his 
concept of the misunderstanding among people as being a result of learned or innate 
preference for verbal processing or visual processing with the historical animosity 
between Greek philosophers Socrates who "heard the voice of his daemon" and 
Protagoras who thinking and debating relied upon visual/kinesthetic processes. 
Richardson quotes Lay as saying "if one is auditory-linguistic he should never enter into 
an argument with a motor-linguistic person, as on all topics except the most concrete 
facts, either will inevitable fail, completely, to understand the other (p. 83)." The 
preference many mathematics students have for either word problems or equations is a 
relatively common example of the encoding, processing and retrieval impact of verbal 
processing or visual/symbolic processing, respectively. Lazarus (1964) deemed visual 
processing to be a crucial factor in systemic desensitization therapy. Now, nearly 40 
years later, the question must be asked if the ability to visualize a virtual counseling 



58 

environment is an individual difference in the ability to developed a therapeutic working 
alliance and produce a satisfactory therapeutic outcome. As potential clients are 
evaluated for cyber counseling, should their preference for verbal processing or visual 
processing be considered? 
Visual Learners 

Maclnnis and Price (1987) summarized the role of visualizing in marketing as "a 
processing mode in which multisensory information is represented in a gestalt form in 
working memory." The visualizers were found to use daydreams and fantasy in addition 
to graphically and pictorial representations in problem solving. Babich (1976) 
operationalizes the visualizing construct as the preference or ability to learn from seeing 
words or numbers and remembering spoken information by writing it down. 
Richardson (1983) found that the visualizer's thinking processes consisted of pictorial or 
visual images. The visualizer attended to the spatial layout, physical features, and 
sensory input of information to be encoded. 
Verbal or Auditory Learners 

Babich, Burdine, Albright & Randol(1976) operationalized the verbalizing 
construct as a preference for hearing words or numbers spoken and noted the common 
practice of verbalizers to vocalize or move the lips or throat while reading written 
materials. Richardson (1983) found that verbalizers' thinking processes consisted of 
spoken words or self-verbalizations, that is, linguistic encoding, labeling or naming. He 
likened it to an experience of inner speech. 



59 

Temperament Learning Styles 

A second widely used learning style indicator has been developed by educators 
using the MBTI temperaments (rather than types). The learning styles are 
SensingPerceiving (SP), SensingJudging (SJ), iNtuitingThinking (NT) and 
iNtuitingFeeling (NF). Dean (1997) noted that these four personality were recognized as 
early as 450 B.C.E. These four temperaments are found in the sixteen types associated 
with the . Gallagher (2002) describes people with the SJ temperament as guardians of 
tradition or traditionalists, learning from the past. People who prefer to use the SP 
functions are artisans and experiencers who learn best from their own work and 
experience. People who draw primarily upon the NT functions learn best conceptually 
looking for rationale, explanation, theories and hypotheses. People who depend most 
strongly on the NF functions are seen as idealists and learn inductively. 
Sensing Perceiving 

Dean (Dean, 1997) proposed that people using the SP function combination or 
temperament are similar to those C.I.T.E. describes a kinetic tactile, preferring hands on 
and active learning situations, which offer the opportunity to construct, operate and 
manipulate objects. 
Sensing Judging 

People using the SJ learn best when their classroom, counseling environment, or 
other learning situation provides clear expectations and a "right way" to do things. Clear 
directions, specific extra-therapy assignments and an overtly structured session are 
valuable assets to learning for those using the SJ functions 



60 

Intuitive Thinking 

People using the NT style learning well from long-term independent projects, 
experimentation, inventions, and complex problem solving. This style is somewhat 
similar to the visualizer and group independent style. 
Intuitive Feeling 

NF users need cooperative personal relationships and learn best in a friendly 
atmosphere. They do not do well in rote, non-democratic environments. They prefer 
ideal relationships and excellent interpersonal communication skills somewhat similar to 
verbal or auditory learners. 
Learning Style Conceptualization Comparison 

It should be noted that although there are some similarities between the CITE, 
learning styles and the MBTI learning styles, they are not redundant and each offer a 
different perspective on learning. Designed for the classroom, the CITE, learning style 
taps actually educational activities preferences in its items and classifications, while the , 
based on the broad Jungian theory of personality and temperament, is more generalized 
and perhaps more applicable to life long learning in an educational format and well as in 
life in general learning. Therefore, both measures were used as independent measures in 
this study. 
Measuring Information Processing 

Richardson (1977) developed the Verbalizer- Visualizer Questionnaire "to access 
the extent to which one's thinking processes consists of words or self verbalization versus 
pictorial or visual images." It consists of 15 forced choice items adapted from Paivio's 



61 

86-item Ways of Thinking Questionnaire. The questionnaire was normed using junior 
high school students. 

While Richardson examined information processing in social psychology, 
education psychologists Babich, Burdine, Albright and Randol (1976), developed a 
learning style inventory, which is widely used today. They targeted three areas of 
concern - information processing, work conditions and expressiveness preference. It is 
the information processing - visualization, verbalization that parallels the social 
psychology work. Items were drawn from the same source material as the Visualizer 
Verbalize Questionnaire, has more extant reliability and validity data, is published and 
readily available, and has been used extensively in education, adult education, career 
counseling and vocational rehabilitation. The Center for Innovative Teaching Experience 
Learning Style Inventory (CITE.) is used by the Veterans Administration and public 
school districts across the country to identify learning styles and to guide instructors, 
counselors and teachers in designing learning experiences to maximize the students= use 
of their preferred learning style. The West Virginia Adult Basic Education program uses 
the CITE as its primary assessment instrument to guide recommendations for tutorials, 
adult learning experiences, and vocational training. 

Myers and Briggs (1962) developed an extensively studied, widely used 
assessment tool, the Myers Briggs Type Indicator (MBTI) to measure the individual's 
trait preferences consistent with Jung's theory. There are four independent dimensions, 
introversion/extroversion; sensing/intuititing; thinking/feeling and judging/perceiving. 
Interpretation of the "type" involves hypotheses about the interactions of these 
dimensions and involves understanding of dominant functions, auxiliary, inferior 



62 

functions, and so forth. The result of an MBTI is one of sixteen types that purport to 
describe a person's inherent functioning and are used to help people understand why 
others respond differently in the same situation. Keirsey and others have focused on 
temperament grouping and developed their own variations on the MBTI; however, the 
MBTI was used for this study because it provided both the learning style data and 
personality trait data discussed below. 

Personality Attitudes 

Except for those clinicians who practice radical behavioralism, individual traits 
play a prominent role in the planning, conduct, process and outcome of psychotherapy. 
Jung (1923) was once of the earliest psychiatrists to postulate personality types. He 
identified polar attitudes that he called introversion and extraversion. In the MBTI user's 
manual, Myers (1962, p. 9) describes extraversion as a trait or attitude of people who 
"like to focus on the outer world of people and activity. They direct their energy and 
attention outward and receive energy from interacting with people and from taking 
action." She describes introversion as an attitude of people who "like to focus on their 
own inner world of ideas and experiences. They direct their energy and attention inward 
and receive energy from reflecting on their thoughts, memories, and feelings." Eysenck 
(1970) suggested that personality is biologically determined and is arranged in a 
hierarchy consisting of types, traits, habitual responses, and specific responses. Eysenck 
built upon Jung's theory with empirical research, describing a structure of personality 
along three dimensions, one of which was introversion-extroversion. Brinegar (1992), 
researching the predictive value of the MBTI in counseling outcome found that 
"extraversion-introversion dimension surfaced as the only single dimension score to be 
significantly correlated with counseling outcome." Myers, as early as 1962, suggested 



63 

implications for counseling based on type and counseling goal - vocational and career, 
education and learning, organizational team building - and provides guidelines for using 
introversion/extraversion (as well as other scales) appropriately in each setting. 
Introversion 

The trait of introversion is generally associated with a preference for 
communicating in writing, working out ideas by reflecting on them, being private and 
self contained, and for taking the initiative when a situation or issue is very important to 
the person (Myers 1962). 
Extraversion 

The trait of extraversion is seen in people who are attuned to their surroundings, 
communicate verbally, problem solving by talking through issues, and learn by doing or 
discussing (Myers 1962). 
Measuring Personality Attitudes 

While Jung, Briggs, Myers, and McCaully all thought and taught that the 
dimensions are dichotomous, several researchers (Mendelson 1965, Girelli & Stake, 
1993) examined the scales as continua and suggested that the forced choice format of the 
forces the bipolarity artifact, underestimating the true continuum of the dimensions. The 
current protocol for scoring the MBTI has keys for calculating the degree of introversion/ 
extraversion for example rather than regarding them as dichotomous categories. For the 
purpose of this study, the scales were treated as discrete traits. 

The dimension relevant to this study is Introversion/Extroversion. Livingood 
(1995) found that "the number of introverts on these (Internet mail lists by MBTI type) is 
five times greater than the number of extroverts. However, in the United States at large, 



64 

introverts are a minority group comprising only 25-30% of the total population, (p. 8)." 
While intriguing, this may be skewed by the obvious fact that the mailing lists are 
presumably drawing from a world population rather than a US population. Livingood 
himself writes from Australia. This perception may also reflect the observation that the 
people who first had access to the Internet and continue to have predominate access to the 
Internet are engineers and scientists who make up that 25%-30% of American introverts 
(Myers 1982). The use of the introversion/extroversion scale in this study is significant 
because the study population is United States citizens or international students choosing 
to study in the United States. The participants were recruited from the College of 
Education rather than engineering or science. 

Counseling Process and Outcome 
During the first half of the 20 th century, researchers primarily focused on 
understanding the psychological processes that affected the well being of the population. 
This research generated the great theories of personality and the applied therapies have 
helped people enjoy a better quality of life for three generations. In the second half of the 
century, researchers began to examine how the therapies produced the results that were 
anecdotally abundant. They examined what factors, conditions and environments that 
increased or decreased the efficacy of therapies. Financial accountability in government 
health care service has driven research in outcome efficacy and consumer satisfaction for 
the past two decades. In the mental health field, this research has taken two primary 
directions, efficacy of the counseling process, the helping relationship, (Gaston 1991, 
Greenson 1965, Hartley & Strupp 1983, Alexander & Luborsky 1986, Klee, Abeles, & 
Muller 1990, Kobotovic & Tracey 1990, Horvath & Symonds 1991, Horvath, Gaston & 
Luborsky 1993, Horvath & Luborsky 1993) and efficacy of the over all experience, 



65 

consumer satisfaction (Becker et al. 2000, Cialo 1982, Eisen, Leff, & Schaefer 1999, 
McCullough 1993, Preston 2000, Treadwiell, Soetikno, & Lenert 2000). 

Working Alliance 

For several decades, researchers have attempted to isolate the therapeutic method 
or technique that was most effective. This research had limited results when the broad 
concept — the interpersonal milieu of therapy, first introduced by Freud as transference 
— was examined. Clarkson distills from the literature and her diverse theory training, 
five relationships between therapist and client, which strongly inform this study. 
Although not all these relationships may exist in any given therapeutic relationship, and 
may not be recognized by all theoretically orientations, each is potentially available 
within computer-mediated therapy as in the face-to-face work, however it was the first, 
the working alliance, with which this study is primary concerned. Identified therapeutic 
relationships include 

• "The working alliance as the part of client-psychotherapist relationship that 
enables the client and therapist to work together even when the patient or client 
experiences strong desires to the contrary. 

• The transferential/countertransferentiaX relationship as the experience of 
unconscious wishes and fears transferred on to or into the therapeutic partnership. 

• The reparative/developmentally-needed relationship as intentional provision by 
the psychotherapist of a corrective, reparative, or replenishing relationship or 
action where the original experience was deficient, abusive or overprotective. 

• The person to person relationship as the real relationship or core relationship as 
opposed to object relationship. 

• The transpersonal relationship as the timeless facet of the psychotherapeutic 
relationship, which is impossible to describe, but refers to the spiritual dimension 
of the healing relationship. (Clarkson, 1995)" 



66 

To measure the presence and relative weight of these constructs research teams at 
the University of Pennsylvania developed the Penn Helping Scale (Alexander & Luborsky 
1986); at Vanderbilt, the Psychotherapy Process Scale and the Negative Indicators Scale 
(Suh, Strupp, & 0*Malley 1986); and at Simon Fraser University, the Working Alliance 
Inventory. (Horvath & Greenberg 1986). These projects all based their work on the 
Bordin's (1976) three-factor operational decimation of the helping, therapeutic, working 
alliance that consisted of interpersonal bond between the client and therapist. This is 
transference/counter transference without a pathological implication. Bordin further 
suggested the need for agreement between the client and therapist as to the goal of therapy 
and agreement as to the tasks required to accomplish this goal. From 1976, Bordin 
maintained that, to be effective, the therapeutic relationship must be collaborative, not 
hierarchical. 
Measuring Therapy Outcome 

Outcome evaluation has evolved from early opinions of the therapists, to complex 
testing using instruments including the MMPI (McCullough 1993), to semantic 
differential studies designed to cover all possible theories available and obfuscate the 
purpose to the measure to avoid contamination (Stiles 1980), to market driven consumer 
satisfaction surveys (Patterson & Leach 1987). Therapist opinion may be highly accurate 
or may be self serving in any given situation. A structured form of therapist opinion has 
been developed and normed over four decades and five versions of the Diagnostic and 
Statistical Manual. (DSM). The Global Assessment of Functioning (GAF) (APA 1994) is 
the most widely used outcome measure because it is the Axis 5 measure, required as part 
of the five-axis mental health diagnostic report. Its use has been increased by the demand 
of most HMO's and PPO's for use of the five-axis system. 



67 

The origin of the GAF is the Health Sickness Rating Scale (HSRS) developed in 
1962. It consisted of thirty case studies and seven scales - "ability to function 
autonomously," "seriousness of symptoms," "degree of discomfort," "effect on 
environment," "utilization of abilities," "quality of interpersonal relationships," and 
"breadth and depth of interest." A single score results as is true for the GAF. These scale 
concepts can still be identified in the descriptions of the levels of functioning in the GAF. 
The Global Assessment Scale (GAS) was a simplified form of the HSRS and has a .9 
correlation with the HSRS. The GAS more closely resembles the GAF, in that it no 
longer has scales or case studies. The descriptions illustrate each 10-point range on a 
scale from to 100. The GAF was identical to the GAS except it had a range of to 90 
in the DSM-III-R, however the scale has been returned to 0-100 in the DSM-IV. 
(McCullough 1993). Other recommended instruments to be included in a "core battery" 
are the Beck anxiety and depression inventories, the Hamilton anxiety and depression 
rating scales, the psychiatric status schedule, the social adjustment scale, the Health- 
Sickness rating scale, the MCMI, the Wisconsin Personality Disorders Inventory and 
such. These measures however are more appropriate to a clinical population that allows a 
statically significant range of change. Nations such as Australia and New Zealand who 
have social health care have conducted extensive outcome scale development and 
utilization studies (Eisen et al. 1999, Preston 2000). While these instruments are much 
more concise and economical than the battery of tests recommended by McCullough, 
they are again more geared to the outcome of clinical populations. 

Consumer satisfaction is a business and marketing concept, which seems to have 
entered the health care environment with managed health organizations. Employee 



68 

Assistance Programs (EAP), social work and rehabilitation counseling seem to be on the 
leading edge of development of these instruments, however, reliability and validity has 
not been rigorously demonstrated. The consumer satisfaction survey is, nonetheless, the 
most appropriate outcome measure for this study of undergraduate students presenting 
with developmental and growth issues. Attkisson et. al (1982) developed a college 
student satisfaction form that was too specific in it items and too long (82 items) to be 
used in this study. 

An outcome satisfaction questionnaire was developed for this study using the 
work Dansky, et al (1996) as a guideline. The items developed were submitted to a 
committee of experts (e.g., Delphi Method for evaluation and were used by counselors 
and students in a pilot study at a local community college. Counselors and students were 
asked to respond to each item based on their experience at the counseling center and to 
offer content, wording, and face value feedback regarding each item. The resulting 
instrument consisted of two forms, one for participants, and one for facilitators. The 
participant form had 12 items, seven Likert-like items about satisfaction with the personal 
growth sessions outcome, two Likert-like items assessing the participant's self perceived 
computer competence, and one Likert-like items eliciting the participants' predicted 
future uses of computer-mediated counseling. Two items were open-ended qualitative 
questions requesting the participants' opinions about the personal growth sessions. The 
computer-mediated aspect was specifically targeted in the qualitative questions to allow 
the participant to appraise his or her experience regardless of assignment to conditions of 
the experiment. The facilitator version had similar session focused items but did not have 
the qualitative items, the computer competence items, or the predicted future use items. 



69 

This information was collected in personal interviews with the facilitators after they had 
completed their all of their sessions with participants. 

A pplication in this Study 

The goal of this study is to contribute meaningful research to under-gird and 
advise the developing phenomena of Internet counseling. The foundation for good 
counseling has been developed over the past century and for good communication over 
the past many millennia. The advent of a new venue for communication and the 
willingness of mental health professional to move out into this venue should surprise no 
one. As counselors boldly go where no one has gone before - providing mental health 
services in cyberspace, research asks What is known about the new environment? What 
needs to be known? What risks can be anticipated? What risks cannot be anticipated? 
What known tools can be used as is? What needs to be retooled? What new tools need 
to be invented? No one study begin to answers do all that, of course. The purpose of 
existing professional literature is to suggest answers or directions to answers for some of 
these questions. 

It seems clear from the literature that a rich very human culture has developed on 
the Internet over the past 30 years, initiated by graduate students at MTT, Stanford and 7 
other prominent universities, who were given carte blanc to "see what could be done" 
with the new technology. Government initiates to provide health care to citizens in 
geographically remote areas and the commercial emergence of Internet use have paved 
the way for cyber-counseling. Cyber counseling appears to lend itself to brief therapy 
with non-crisis clients. Several years of cyber counseling practice have created a need 
for research to determine the efficacy of cyber counseling and to suggest predictive 
criteria for screening potential clients for appropriateness for cyber counseling. Many 



70 

questions need to be explored. There are several technologies that can be used - virtual 
reality, web-cam live transmissions, individual written messages (email), public written 
messages (bulletin boards), and live written messages (chat rooms). The Internet lends 
itself to group interaction, but individual intimacy is also well represented. The scope of 
this study was confined to individual therapy in a live (synchronic) written format. The 
individual differences the participant brings to the personal growth computer-mediated 
sessions were compared to those that they bring to traditional face-to-face sessions. 



CHAPTER 3 
METHODOLOGY 

Statement of Purpose 

The purpose of this study is to examine the efficacy of Internet counseling. Chat 
room counseling was compared with traditional face-to-face counseling. Similarities and 
differences were measures for therapist -participant alliance and for outcome. Four of the 
multitude of individual differences, gender, ethnicity, personality, and information 
processing, that each participant brings to the therapeutic setting, were measured to 
determine is any difference in impact can be discerned in the face-to-face or computer- 
mediated condition. This chapter presents the research hypotheses, dependent and 
independent variables, sample population, procedures for training the facilitators, 
procedures for the implementation of the personal growth sessions, instrumentation, 
experimental conditions and assignment to conditions, data collection and statically 
analysis. 

Hypotheses 

The study will test the following null hypotheses: 

Hoi: There is no significant difference in the client reported quality of the 

working alliance when counseling is delivered face-to-face or computer- 
mediated regardless of gender, ethnicity, personality style, learning style. 

Ho2: There is no significant difference in outcome efficacy when counseling is 
delivered face-to-face or computer-mediated regardless of gender, 
ethnicity, personality style, or learning style. 

Ho3a: There is no significant relationship between the client reported quality 
of the working alliance and gender in CM Counseling. 



71 



72 



Ho3b: There is no significant relationship between in the outcome efficacy 
and gender in CM Counseling. 

Ho3c: There is no significant relationship between the client reported quality of 
the working alliance and gender in F2F counseling. 

Ho3d: There is no significant relationship between the outcome efficacy and 
gender in F2F Counseling. 

Ho4a: There is no significant relationship between the client reported quality 
of the working alliance and ethnicity in CM Counseling. 

Ho4b: There is no significant relationship between the client reported 
outcome satisfaction and ethnicity in CM Counseling. 

Ho4c: There is no significant relationship between the client reported quality of 
the working alliance and ethnicity in F2F counseling. 

Ho4d: There is no significant relationship between the outcome efficacy and 
race/ethnicity in F2F Counseling. 

Ho5a: There is no significant relationship between the client reported quality 

of the working alliance and visualizing learning style in CM Counseling. 

Ho5b: There is no significant relationship between the client reported 

outcome satisfaction and visualizing learning style CM Counseling. 

Ho5c: There is no significant relationship between the client reported quality of 
the working alliance and verbalizing learning style in F2F counseling. 

Ho5d: There is no significant relationship between the outcome efficacy and 
verbalizing learning style in F2F Counseling. 

Ho6a: There is no significant relationship between the client reported quality of 
the working alliance and introversion in CM Counseling. 

Ho6b: There is no significant relationship between the client reported outcome 
satisfaction and introversion in CM Counseling. 

Ho6c: There is no significant relationship between the client reported quality of 
the working alliance and extraversion in F2F counseling. 

Ho6d: There is no significant relationship between the outcome efficacy and 
extraversion in F2F Counseling. 



73 

Descriptions of Variables 
The research design consists of random assignment of participants to one of two 
conditions. The conditions are face-to-face personal growth sessions and computer- 
mediated chat room personal growth sessions. Because the participants were randomly 
assigned to one of the two conditions, post-test only were used to measure the variables. 
RO 3 face-to-face personal growth sessions Posttests 

Rl 3 computer-mediated personal growth sessions Posttests 
The three sessions were conducted to facilitators who will work with an equal 
number of participants in each condition, that is, if a facilitator works with a total of 10 
participants, he or she will conduct three sessions face-to-face with 5 participants, 
individually, and 5 sets of sessions via computer chat room. Ten graduate students 
representing a broad population of counselors (1 male, 9 females; 1 African American, 1 
Hispanic; 3 licensed mental health counselors, 3 certified rehabilitation counselors; age 
range 23 to 56), from counselor education and rehabilitation counseling were hired and 
trained to conduct the personal growth sessions. The participants received extra credits in 
their counselor education interpersonal skills, substance abuse, or stress management 
classes, at the discretion of their instructor. The quality of the working alliance and the 
outcome satisfaction were measured to evaluate and compare the counseling experience 
in the two conditions. The individual differences that participants bring to the experience 
were measured to determine if any and which differences might predict better success 
with one condition or the other. For example, do introverted participants do better in one 
condition than they do in the other? Do African American participants benefit more from 
one condition than they do in the other? Is there any difference in the working alliance 
developed by participants with a verbal learning style in one condition versus the other? 



74 

This could be a valuable contribution to pre-screening criteria for clients who apply for 
computer-mediated counseling. 
Dependent Variables 

There are two sets of dependent variables in this study, the participant perceived 
quality of the working alliance during counseling and the participant's report of outcome 
satisfaction with the personal growth counseling received plus the facilitators opinions on 
the same concepts. The working alliance is a process construct thought to describe the 
counselor-client relationship as it pertains to providing a helping environment for therapy 
to occur. It was measured with the Working Alliance Inventory. The clients' outcome 
satisfaction is a product construct that taps the results or benefits gained in therapy. It 
was measured with Outcome Satisfaction Questionnaire developed for this study and 
described above. 
Independent Variables 

The independent variables race/ethnicity, gender, learning style and 
introversion/extroversion were investigated in this study. Ethnicity is an important 
variable because while the Internet makes democracy — the free exchange of information 
and universal individual input - more available to many, there is realistic concern that 
some are marginalized because of limited access to technological resources and 
strategically administered corporate or organization control of resources (Mantovani, 
2001, p. 51). 

Gender has been suggested as a differential variable in cyberspace. Men have 
long dominated math, science and engineering careers. Internet access and savvy have 
grown out of training, familiarity and experience with computer technology. Therefore, 
there is concern that women have not had the exposure to computer technology to make 



75 

this form of communication and counseling available to them. There is also concern that 
as women are thought to be more relational in their orientation while men are more 
analytical, computer-mediated counseling may disadvantage female clients. 

Learning styles that favor visual learning, written expressiveness and/or 
individual work may be more adaptive to Internet counseling while verbal learning, oral 
expressiveness and/or group work may be disadvantaged in a computer-mediated 
environment. 

Personality type, likewise, may predispose some clients to more comfort and 
effectiveness using computer-mediated counseling and disadvantage others. The 
personality trait introversion/extroversion was an independent variable to determine if 
introversion is predictive of great outcome satisfactions than extroversion. 

Population 

The population was a southern university undergraduate population and from a 
community college in the same locale, with an age median of 20. This population is 
thought to be representative of computer users who use computers for social as well as 
technical purposes, have grown up in a technological age, and are of the age and social 
class most representative of computer users. Undergraduates volunteered for the study 
after hearing a presentation in their classroom, completing a contact sheet with 
demographic information, and signing an informed consent. They were provided with a 
duplicate of the informed consent form and were randomly assigned to personal growth 
sessions in either a face-to-face or computer-mediated counseling condition. Participants 
were enrolled in stress management, substance abuse, or interpersonal skill classes in the 
department of counsel education or in the student development classes at the community 
college. Students (N = 123; M = 29; F = 94) were contacted by their facilitator and 



76 

scheduled for sessions. Upon the completion of three personal growth sessions, the 
participant completed the MBTI, the CITE, the W AI (c) and the OSQ (p) in an encrypted 
website monitored by a survey technician available in chat room 5 of the site who was 
trained to answer any questions about the mechanics of completing the instruments that 
arose. The facilitator, who was not the monitor, completed the WAI (t) and the OSQ (f). 

Sampling Procedures 
Volunteers were recruited from the population of students enrolled in 
undergraduate counseling education classes in interpersonal skills and stress 
management. Most participants received a small amount (no more than 2% of grade) of 
class credit for participation and three sessions of personal growth guidance. Participants 
were quasi-randomly assigned to the twelve facilitators and were randomly assigned to 
face-to-face or computer-mediated study conditions. Exceptions were made to random 
assignment to facilitators if the facilitator knew the participant or if the facilitator and 
participant were unable to find a mutually convenient time to meet. The facilitator each 
conducted an equal number of face-to-face and computer-mediated sessions. Pre- 
induction paperwork included an informed consent, assurance that volunteers are at least 
18 years of age, and provision of a code for confidential contact, a phone number, and/or 
an email address. All volunteers had adequate computer ability so that they could be 
randomly assigned to conditions. The university requires these skills of undergraduates 
and requires all undergraduates to own or have access to a computer with sufficient 
application software to participate in this study. The computer-mediated sessions were 
conducted in the university electronic learning gateway system WebCT. Many classes 
are offered or supplemented through this system so all students can be expected to learn 
how to use it at some point in their undergraduate career. The university has a computer 



77 

help desk for students who have any difficulty accessing or using the system and 
participants were notified of these services. 

Midway through the study, the University moved WebCT to an authenticated server 
that required identification at log on. However, the university maintained the original 
server for studies such as this that require anonymous or coded logon. This did not 
negatively affect the study in any way because site appearance remained the same to the 
facilitators and because the participants had never seen the other system. When 
participants navigated to the WebCT home page, they found this among other studies 
listed individually with a link to the older server (e.g. Participants in the Groble 
dissertation study click here) . The one possible confound was that the new server 
relieved the lag time problem encountered in the spring term when the old server was 
overloaded. Facilitators either did not notice or did not mention any difference. The lag 
was inconsistent in the spring depending on the time of day of appointments.. The lag 
occurred when the system was experiencing heavy use throughout the university. The 
facilitators may have adjusted their scheduling to minimize this problem. 

Data Collection Procedures 
The principal researcher established a dedicated, password secured web site with 
a text-talk (chat room) application for use by facilitators who conducted the personal 
growth sessions and data collection. Recruitment was conducted in the source 
classrooms during regularly scheduled class with the instructor's permission to discuss 
the study, explain the participants' rights to withdraw without harm, obtained informed 
consent and contact information. The principal researcher did not access to the web site 
once the study begins and each assistant was instructed how to secure his or her 



78 

participants' sessions. Sessions were downloaded with the permission of the participant 
for further research analysis outside the scope of this study. 

Nine graduate students and one recent graduate from the Department of 
Counselor Education or the Department of Rehabilitation Counseling were trained in the 
study protocol, study logistics, cognitive behavior therapy principles, WebCT use, 
Internet Resources for clients, and research on the typical personal growth issues of 
undergraduates. All trainings were conducted in person by the principal investigator who 
prepared the extensive, detailed manual each facilitator received. Additional computer 
specific training was provided by the principal investigator and by University personnel 
familiar with the WebCT resources. The principal investigator coordinated with the 
instructors for the interpersonal communications, substance abuse, student development, 
and stress management classes to present the study during class early in the term and 
recruit participants. Participants were contacted individually, randomly assigning to one 
of the two conditions, scheduled for first session, given any direction needed for finding 
the counseling lab or WEBCT chat room. The principal investigator was available via 
beeper during any sessions to insure the safety of participant and availability to the 
graduate student facilitators. Facilitators received weekly supervision in accordance with 
their program requirements (practicum, research, registered intern, and such) and project 
design. 

The participants presented genuine concerns common to college undergraduates 
such as but not limited to adjustment to college life, time management, study habits, 
career indecision, roommate relations, and so forth. The facilitator contacted each 
participant to set up the first meeting. He or she gave directions for participation. When 



79 

the participant was assigned to the face-to-face condition, the facilitator ensured that the 
participant understood where and when to meet with the facilitator. When the participant 
was assigned to the computer-mediated condition, the facilitator provided direction for 
the participant to log on to the chat room at the appropriate time and ensured that the 
participant understood how to log on to the system and navigate to the chat session space. 
The logistic of the experiment, detailed session outlines, record keeping forms, and the 
required readings list are located in the facilitators training manual in Appendix B. 

Instrumentation 
Working Alliance Inventory (Client) 

The Working Alliance Inventory Client (WAI c) is a 36 item developed by 
Horvath (1984b, 1986) to be used early in the relationships between the 3 rd and 5 th 
session. It was administered at the end of the 3 rd session for purposes of this research. 
The Working Alliance Inventory targets the client-therapist relationship in a pan- 
theoretical approach. (Horvath et al. 1993 p. 255). It was designed to be counseling 
theory neutral while operationalizing Bordin's description of the three factor working 
alliance - tasks, goals, and bond (Horvath & Greenberg, 1986). The WAI consists of 36 
items, 12 relating to each of the factors of the working alliance. The WAI, client version 
has a Hoyt's estimate of reliability of .88 for the goal and task subscales, a Hoyt's 
estimate of reliability of .85 for the bond subscale and a Cronbach's alpha of .93 for the 
composite (Horvath & Greenberg, 1986). Items are rated on a Likert-like scale from one 
being never to seven being always. 

Sample items (Horvath, 1984b) 

"I find what I am doing in therapy confusing" (Tasks) 
"I am worried about he outcome of these sessions" (Goals) 
"(name of counselor) and I understand each other." (Bond) 



80 

The advantage of these measure are that they have forms for both the participant 
and the therapist providing the opportunity to view the therapeutic relationship through 
both lenses. The forms are attractive, well researched and easy to understand and 
complete with a minimum of time and effort on the part of the participant. The questions 
are non-threatening and non-intrusive while tapping all three aspects of the working 
relationship defined by Bordin and fundamental to all therapeutic relationship 
instruments examined. 
Working Alliance Inventory (Therapist) 

The Working Alliance Inventory Form T is the therapist version that assesses the 

therapist view of the working alliance across all three components of bond, task 

agreement and goal agreement. 

Sample items (Horvath, 1984a) 

"I feel uncomfortable with . (bond) 

My client and I both feel confident about the usefulness of our current 
activity in therapy, (tasks) 
and I have a common perception of her/his goals, (goals) 

Outcome Satisfaction Questionnaire 

An outcome satisfaction questionnaire was developed for this study because 

outcome measure reviewed in the literature emphasized medical diagnosis and 

symptomatology or were site specific dealing with the mechanics of scheduling 

appointments and locating offices. Items for this outcome measure were written by the 

principle investigator or adapted from existing instrument where applicable. A 

committee of experts reviewed the potential items. A pilot study of the instrument was 

conducted at a local community college to gather feedback from students receiving 

counseling and from counselors regarding item wording, appropriateness, and face value. 

Information from the committee and from the community college study were 



81 

implemented into the final 12 item form developed for participants and 7 item form 
developed for facilitators. The facilitator form did not include qualitative questions 
found on the participant form. 

Students rated their perception of their computer skills and their likelihood of 
seeking Internet counseling should they seek counseling in the future. They answered 
open-ended questions about what they least liked about computer-mediated 
communication as they had experienced it in this study and were encouraged to offer 
suggestions, comments, and ideas about the Internet interaction study. Facilitators were 
trained in adequate computer skills, as needed, before beginning their work on this 
project and were individually debriefed about the other points in end of study interviews. 
Myers Briggs Type Indicator Form M (MBTI) 

The MBTI is arguably the most researched and most widely used personality 
instrument. The Singer-Loomis Type Deployment Instrument (Singer 1996) and Keirsey 
Type Indicator (1984/1996) are similar Jungian theory based instruments but less 
researched and less often applied. The Keirsey Type Indicator is readily available on the 
Internet, although no longer free. The Singer-Loomis is still considered to be a research 
tool, and as such not used in applied setting such as business, counseling, and career 
development. The strength of the Singer-Loomis is that it is built upon a dynamic theory 
of personality growth and change rather than what has been seen as the rather static 
typing of the MBTI . The MBTI, however, was used in this study because the 
introversion/extroversion scale has consistently been found to have predictive and 
discriminative value. The Keirsey and Singer Loomis blend the four scales while the 
MBTI is more consistent with Jung's theory that introversion/extroversion is a attitude, 
while thinking/feeling and intuition/ sensing are traits. It is the introversion/extroversion 



82 

scale of the MBTI that was used in this study. Eysenck developed an 
introversion/extroversion scale as part of his three factors biologically based formulation 
of personality; however, it is more applicable to a clinical population than the population 
of this study. 

The MBTI is statistically sound. The phi coefficient for reliability ranges from 
.55 to .65 for the introversion/extroversion dimensions; .64 to .53 for the sensing/intuiting 
dimension; .43 to .75 for the thinking/feeling dimension and .58 to .84 for the 
judging/perceiving dimension. The tetrachoric coefficients are higher, .70 to .81 for I/E; 
.82 to . 92 for S/N; .66 to .90 for T/F and .76 to .84 for J/P. Reliability is found to 
increase with the population's age and intelligence. When the data were converted to 
continuous scores the reliability estimates are more consistent at .76 to .82 I/E; .75 to .87 
S/N; /69 to .86 T/F and .80 to .84 J/P. (Willis, 1984). Table 11.1 (Myers & McCaulley 
1993, pp. 177-206) describes the validity studies correlations between the MBTI and the 
Adjective Check List by scales, the California Psychological Inventory by scales, the 
Comrey Personality Scales, by scales, the Edwards Personality Preference Survey by 
scales, the Emotions Profile Index by scales, the Eysenck Personality Questionnaires by 
scales, the Maudsley Personality Inventory by scales, the Jungian Type Survey by scales, 
the Minnesota Multiphasic Personality Inventory by validity and clinical scales, the 
Omnibus Personality Inventory by scales, the Personality Research Inventory by scales, 
the Stein Self Description Questionnaire by scales, the Brown Self Report inventory by 
scales, the Sixteen Personality Factor Questionnaire by scales and by second order traits, 
the State-Trait Anxiety Inventory by state and trait, the Study of Values by scales, The 
Rokeasch Dogmatism Scales, the Opinion, Attitude and Interest Scale by scales, the 



83 

Kuder Occupational Interest Survey by college major and occupational scales, the 

Strong-Campbell Interest Inventory (now known as the Strong Interest Inventory) by 

occupational themes, the Kolb Learning Style Inventory by scales, the Science Research 

Temperaments Scale, the Watson Glaser Critical Thinking Appraisal, and lesser known 

instruments including the Conflict Management, the Harbaugh (W)holistic Scales, the 

Internal-External Locus of Control and the Intolerance of Ambiguity. The body of work 

establishes the MBTI construct validity, divergent and convergent validity. 

Center for Innovating Teaching Experiences Learning Styles Inventory (CITE) 

The Center for Innovative Teaching Experience, Murdock Teacher Center, 

Wichita Kansas School District developed the Learning Style Inventory most prevalently 

used in education today. The CITE Learning Style Instrument is composed of 45 items 

that the respondent scores 4, 3, 2, or 1 . A score of 4 on an item means that the respondent 

feels the statement is "most like me" while a score of 1 indicates that the statement is 

"least like me". Results were calculated for nine subscales, visual language, visual 

numerical, auditory language, auditory numerical, kinesthetic-tactile, social-individual, 

social-group, expressiveness-oral and expressiveness-written (Babich et al., 1976). For 

the purposes of this study, the visual numerical and auditory numerical are thought to be 

irrelevant to the counseling context but were analyzed in case they tap symbolic 

language. Items were scored for each category and significance or "major learning style" 

is determined by a cut score of 33 on any scale. The split-half reliabilities were .6 or 

better for eighty-five percent of the constructs. 

Sample items (Babich et al., 1976) 

"I remember things I hear better than I read" (Auditory) 
"I would rather read a story than listen to it read." (Visual) 



84 

Richardson developed a visualize verbalizer scale; however, it has not been used 
outside research and is thought to be less applicable to this study than the visual and 
auditory scales of the CITE that has been widely used with adult populations and normed 
to the same population as this study. Richardson's scale was normed to a middle school 
population and the norming sample was small. 
Demographics 

Participants were asked to indicate their age, gender, and race or races. It seems 
unlikely that the population of convenience have have any significant variance in age or 
gender but these questions were asked in case the perception of homogeneousness is 
erroneous. The age question was not relevant, however the gender question returned 
essential data. The ethnic composition of the population of this study was expected to be 
diverse and thought have significance in the working alliance and outcome of the face-to- 
face or computer-mediated sessions. 

Data Analyses Procedures 

Data were analyzed using SPSS 11.0. ANOVA procedures were used to analyze 
the data because this procedure is sensitive to relationships between the independent 
variables, gender, ethnicity, learning style and personality traits and the dependent 
measures. Means and standard deviation were computed for all significant main effects 
and interactions to evaluate the efficacy of computer-mediated counseling compared to 
face-to-face counseling in the process dimension, working alliance and the outcome 
dimension efficacy. 



CHAPTER 4 
DATA ANALYSIS 

The purpose of this study was to evaluate the efficacy of brief, cognitive 
behavioral therapy provided on the Internet in real time chat room modality. The study 
compared two sets of participants. Participants in one set met with the protocol trained 
graduate counseling student facilitators face-to-face. Participants in the other set met 
with protocol-trained graduate counseling student facilitators via the Internet in a 
University of Florida, WebCT, classroom chat room. All participants and all facilitators 
completed the dependent variable surveys via the Internet through the WebCT evaluation 
utility that provided anonymity for surveys. The chat room was set up so that participants 
entered by code rather than by name. 

Descriptive Statistics for Dependent Measures 

This study used four instruments as dependent variables. Two forms of The 
Working Alliance Inventory were used, form c for clients and form t for therapist. The 
Working Alliance Inventory provided a total score as well as three sub scores per version. 
The student version of the Outcome Satisfaction Questionnaire measure provided three 
scores and qualitative responses for future analysis. Common to both the participant 
form and facilitator form was the outcome satisfaction scale. In addition, participants 
estimated their computer use skill on a Likert-like scale and predicted the likelihood that 
they would choose computer-mediated counseling in the future. High scores indicate 
positive responses for the WAI while low scores report favorably on the OSQ. That is, 
the closer a participant's score is to the minimum for outcome satisfaction, predicted 

85 



86 

future use, and computer skill the greater their positive response. The closer a person's 
score is on any of the WAI versions or scales is to the maximum, the more positive the 
response. 

The data was evaluated using analyses of variance (ANOVA), that require that the 
independent variable or factor consist of two or more levels and that those levels cover all 
possible levels of interest to the researcher (e.g., male, female). The levels were 
qualitative (e.g., face-to-face, computer-mediated personal growth sessions) or 
quantitative (e.g., MBTI introversion/extraversion). The participant endorsed one and 
only one level of each factor. Each independent variable in this study met the criteria. 
The critical F value to disprove the Null hypothesis at the .05 confidence level is F (critical 
i, 123) = 3.92. The independent factors or variables were condition to which the participant 
was randomly assigned, ethnicity, gender, academic learning style, personality attitude, 
temperament learning style. 

Table 1 depicts the meaningful descriptive statistics for the independent variables 
- gender, ethnicity, academic learning style, trait learning style, and attitude - and for the 
dependent variables - working alliance, by scales, outcome satisfaction, predicted future 
use, and computer/Internet skill level. The table is organized by experimental conditions, 
face-to-face and computer-mediated treatments. Table 2 presents the factors and levels 
of each factor used in the analyses of variance. 

Participant Dependent Variables Analysis 

To evaluate outcome efficacy, participants were asked to evaluate the quality of 
their experience in the face-to-face or computer-mediated conditions and their outcome 
satisfaction. They were asked to predict if they thought they would be likely to use 
computer-mediated counseling in the future. They were asked to describe their comfort 



87 



and skill level with using a computer and using the Internet. To allow the researcher to 
examine the process efficacy of these sessions in the two conditions, participants 
answered questions about their total evaluation of the working alliance they co-created 
with their facilitator. 
Table 1 Descriptive Statistics for Dependent Variables by Conditions 



Variables 


N 


Minimum Maximum 


Mean 


Std. 












Deviation 


FACE-TO-FAC 








WAI Task (client) 


59 


7 


44 


32.88 


8.748 


WAI Bond (client) 


59 


14 


60 


46.00 


10.609 


WAI Goal (client) 


59 


2 


36 


25.05 


8.330 


WAI Total (client) 


59 


23 


140 


103.93 


24.676 


Satisfaction (participant) 


59 


7 


27 


12.64 


4.877 


Computer Skill participant) 


59 


2 


7 


4.00 


1.218 


Predicted future use (participant) 


59 





3 


.95 


.705 


WAI Task (therapist) 


58 


-4 


42 


27.74 


9.049 


WAI Bond (therapist) 


58 


30 


60 


49.31 


8.217 


WAI Goal (therapist) 


58 


-14 


33 


18.74 


10.597 


WAI Total (therapist) 


58 


17 


127 


95.79 


25.360 


Satisfaction (therapist) 


58 


8 


23 


15.83 


3.738 


COMPUTER-MEDIATED CONDITIO* 


f 






WAI Task (client) 


64 


11 


44 


31.27 


8.016 


WAI Bond (client) 


63 


23 


60 


45.67 


8.160 


WAI Goal (client) 


63 


3 


36 


24.13 


7.722 


WAI Total (client) 


63 


52 


137 


101.22 


21.372 


Satisfaction (participant) 


63 


7 


24 


13.76 


4.294 


Computer Skill participant) 


63 


2 


10 


4.27 


1.096 


Predicted future use (participant) 


63 





2 


.70 


.687 


WAI Task (therapist) 


63 


2 


44 


28.65 


9.172 


WAI Bond (therapist) 


63 


34 


60 


48.86 


7.118 


WAI Goal (therapist) 


63 


-8 


36 


19.57 


10.171 


WAI Total (therapist) 


63 


29 


137 


96.84 


24.022 


Satisfaction (therapist) 


64 


7 


25 


16.42 


4.227 



The inventory subscales indicated the strength of the personal relationship (bond), 
the mutual creations of tasks, which would lead to accomplishing the goal set for these 



88 

sessions, and ability to delimit, define and specify a goal. The results of their responses 
are discussed in the text below and displayed in tables three through twenty-four below. 



Table 2: Independent Variables, Levels of Each Variable and Number of Participants at 
Each Level 



Factors 



Levels 



Number of 
participants 



Conditions 

Gender 

Ethnicity 

Academic Learning Styles 
Introversion/ Extraversion 
Temperament Learning Styles 



Face-to-face 


58 


Computer-mediated 


64 


Male 


29 


Female 


94 


Caucasian 


94 


African American 


12 


Hispanic 


17 


Visual learners 


30 


Verbal learners 


93 


Extraverts 


88 


Introverts 


35 


Intuitive Thinking (NT) 


18 


Intuitive Feeling (NF) 


53 


Sensing Judging (SJ) 


41 


Sensing Perceiving (SP) 


11 



Predicted future use (participant) 

Participants were asked to predict the likelihood that they would choose 
computer-mediated counseling should they decide to seek out counseling of their own 
volition rather than being randomly assigned to a condition as in the present study. Table 
3 shows the results of the ANOVA. The main effect, learning style, was significant (F = 
4.25, p = .042) but no interactions between face-to-face or computer-mediated counseling 
and the independent variables were significant. 



89 



To further analyze the relationship between academic learning style preference 

and predicted use, follow up tests were applied. For this variable, the lower value 

indicates preference and the higher the score indicates negative responses. 

Table 3 Source Table Dependent Variable — participant predicted future use of 
computer-mediated counseling 



Sources of Variance 


Type III Sum 
of Squares 


df 


Mean 
Square 


FSig. 


Corrected Model 


7.673 


17 


.451 


.897.580 


Intercept 


15.869 


1 


15.869 31.520.000 


Condition 


.280 


1 


.280 


.556.457 


Gender 


.319 


1 


.319 


.633 .428 


Ethnicity 


6.576E-02 


2 3.288E-02 


.065.937 


Academic Learning Sif|§ 


2H1 


1 


2141 


4.253 .042 


Introversion/Extraversion 


8.222E-04 


1 8.222E-04 


.002.968 


Temperament Learning Style 


1.139 


3 


.380 


.754.522 


Condition by Gender 


2.739E-02 


1 2.739E-02 


.054.816 


Condition by Ethnicity 


.319 


2 


.159 


.317.729 


Condition by Academic Learning Style 


.113 


1 


.113 


.224.637 


Condition by Introversion/ Extraversion 


.606 


1 


.606 


1.204.275 


Condition by Temperament Learning Style 


.309 


3 


.103 


.205.893 


Error 


52.360 104 


.503 




Total 


142.000 122 






Corrected Total 


60.033 


121 







Table 4 displays the resulting means and standard deviation. Those who use a visual 

learning style predicted that they would be more likely to seek computer-mediated 

counseling should they need counseling in the future (M = .56 SD = .58), consistent with 

the study hypothesis that visualizers would be more likely to seek computer-mediated 

counseling than verbal or auditory learners (M = .89, SD = .72). 

Table 4. Means and Standard Deviation for Significant Main Effect Academic Learning 
Styles; Dependent Variable — Predicted Future Computer-Mediated Counseling Use 



Academic Learning Style Preference 

Visual learners 
Verbal learners 



Mean 
.89 



Std. Deviation 

1583 
.720 



90 

Level of Computer/Internet Skill 

Academic learning style produced a significant main effect when participants 
were asked to describe their level of comfort using computer and the Internet and their 
computer and Internet skill level (F = 3.95, p = .049). Table 5 depicts all of the results of 
the analysis for this dependent variable. The lower scores indicated greater comfort and 
skill while the higher scores indicate less comfort. Participants who endorsed the visual 
learning style preference estimated their computer skill to be more limited (M = 4.56, SD 
= 1 .53) than did participants who endorsed the verbalizer or auditory learning style 
preference (M = 4.03, SD = 1 .03), contrary to expectation. Verbalizers had better skills 
and greater comfort but visualizers predicted greater future use. 
Table 5. Source table for dependent variable — computer/internet skill level (participant) 





Type III Sum 


df 


Mean 


FSig. 


Sources of Variance 


of Squares 




Square 




Corrected Model 


28.445 


17 


1.673 


1.297.209 


Intercept 


532.841 


1 


532.841412.975.000 


Condition 


.804 


1 


.804 


.623 .432 


Gender 


2.929 


1 


2.929 


2.270.135 


Ethnicity 


4.740 


2 


2.370 


1.837.164 


Academic Learning Style 


1100 


1 


5.100 


3.953.049 


Introversion/ Extraversion 


5.866E-02 


1 5.866E-02 


.045 .832 


Temperament Learning Style 


4.434 


3 


1.478 


1.145.334 


Condition by Gender 


7.398E-02 


1 7.398E-02 


.057.811 


Condition by Ethnicity 


.876 


2 


.438 


.340.713 


Condition by Academic Learning Style 


2.417 


1 


2.417 


1.873.174 


Condition by Introversion/ Extraversion 


.282 


1 


.282 


.218.641 


Condition by Temperament Learning Style 


4.021 


3 


1.340 


1.039.379 


Error 


134.186 104 


1.290 




Total 


2253.000 


122 






Corrected Total 


162.631 


121 







a R Squared =175 (Adjusted R Squared = .040) 



91 

This result is interesting and should be interpreted with caution because it is likely that 

the instrument eliciting skills and comfort may need to be enhanced for greater accuracy 

(see discussion, chapter 5). . 

Table 6. Means and Standard Deviation -Dependent Variable, level of computer/ 
Internet skill and comfort (participant), Independent Variable, academic learning style. 



Academic Learning Style 



Mean 



Std. Deviation 



Visualizer 
Verbalizer 



4.56 
4.03 



1.530 
1.025 



Outcome Satisfaction (Participant) 

Participants' responses about their outcome satisfaction did not produce any 
significant main effect or interaction in the outcome satisfaction measure (Table 7). 
Table 7. Source table for dependent variable — outcome satisfaction (participant) 



Sources of Variance 


Type III Sum 
of Squares 


df 


Mean 
Square 


F 


Sig- 


Corrected Model 


356.389 


17 


20.964 


.989 


.476 


Intercept 


5308.807 


1 


5308.807250.434 


.000 


Condition 


16.177 


1 


16.177 


.763 


.384 


Gender 


25.548 


1 


25.548 


1.205 


.275 


Ethnicity 


84.967 


2 


42.484 


2.004 


.140 


Academic Learning Style 


7.598 


1 


7.598 


.358 


.551 


Introversion/ Extraversion 


9.763 


1 


9.763 


.461 


.499 


Temperament Learning Style 


59.018 


3 


19.673 


.928 


.430 


Condition by Gender 


31.766 


1 


31.766 


1.499 


.224 


Condition by Ethnicity 


29.799 


2 


14.899 


.703 


.498 


Condition by Academic Learning Style 


5.441E-02 


1 5.441E-02 


.003 


.960 


Condition by Introversion/ Extroversion 


24.616 


1 


24.616 


1.161 


.284 


Condition by Temperament Learning Style 


24.496 


3 


8.165 


.385 


.764 


Error 


2204.636 104 


21.198 






Total 


23887.000 122 








Corrected Total 


2561.025 121 









a R Squared =167 (Adjusted R Squared =021) 

The most positive outcome satisfaction score possible was seven. The score indicating 

the greatest possible dissatisfaction with the experience was twenty-eight. The observed 



92 



score range was from seven to twenty-seven in the face-to-face condition (M = 12.64, SD 
■ 4.88) and from seven to twenty-four in the computer-mediated condition (M = 13.76, 
SD = 4.29). This does not mean that the participants were dissatisfied with their 
experience but that the measure of satisfaction did not detect any independent variables 
that influenced satisfaction. In other words, the participants were equally satisfied in 
either experimental condition and regardless of individual differences. 
Working Alliance Inventory Total (Client) 

The Working Alliance Inventory provided four measures, a total rating, and three 
subscale scores. The subscales measured bond, similar to rapport, agreement on goal to 
be achieved in counseling, and agreement of task(s) to be developed to accomplish the 
agreed upon goal of this episode of brief counseling. There were no significant main 
effects or interactions for the dependent variable WAI (c) total score (Table 8). 
Table 8. Source table for dependent variable — WAI (c) Total score 



Sources of Variance 


Type ffl Sum 
of Squares 


df 


Mean 
Square 


FSig. 


Corrected Model 


9574.904 


19 


503.942 


.947.528 


Intercept 


216085.736 


1216085.736 406.031.000 


Condition 


521.780 


1 


521.780 


.980.324 


Gender 


153.238 


1 


153.238 


.288.593 


Ethnicity 


817.424 


2 


408.712 


.768.467 


Academic Learning Style 


1251.056 


2 


625.528 


1.175.313 


Introversion/ Extraversion 


109.434 


1 


109.434 


.206.651 


Temperament Learning Style 


1433.145 


3 


477.715 


.898.445 


Condition by Gender 


817.339 


1 


817.339 


1.536.218 


Condition by Ethnicity 


833.397 


2 


416.698 


.783.460 


Condition by Academic Learning Style 


36.584 


2 


18.292 


.034.966 


Condition by Introversion/ Extraversion 


206.308 


1 


206.308 


.388.535 


Condition by Temperament Learning Style 


2112.052 


3 


704.017 


1.323.271 


Error 


54618.875 ! 


104 


525.181 




Total 


1346441.000 122 






Corrected Total 


63858.369 121 







a R Squared = . 126 (Adjusted R Squared = -.026) 



93 

Working Alliance Inventory Bond (Client) 

There were no significant main effects or interactions for the dependent variable 
working alliance (c) bond,(Table 9). 
Working Alliance Inventory Task (Client) 

There were no significant main effects for independent variables by WAI (c) task 
sub scale (Table 10), however there was a significant interaction between condition and 
gender (F= 3.92, p = .05). Unlike the scores on the Outcome Satisfaction Questionnaire, 
where lower scores were more positive than higher scores, the Working Alliance 
Inventory is scored so that the higher the score the great the positive response. Table 1 1 
shows the means and standard deviation for gender by condition. 
Table 9. Source table for dependent variable — WAI (c) Bond sub score 



Sources of Variance 


Type HI Sum 
of Squares 


df 


Mean 
Square 


FSig. 


Corrected Model 


1550.132 


19 


81.586 


.914.568 


Intercept 


43334.786 


143334.786485.237.000 


Condition 


2.012E-04 


1 2.012E-04 


.000.999 


Gender 


9.003 


1 


9.003 


.101.752 


Ethnicity 


312.180 


2 


156.090 


1.748.179 


Academic Learning Style 


180.325 


2 


90.162 


1.010.368 


Introversion/ Extraversion 


6.755 


1 


6.755 


.076.784 


Temperament Learning Style 


461.944 


3 


153.981 


1.724.167 


Condition by Gender 


7.433 


1 


7.433 


.083 .774 


Condition by Ethnicity 


232.154 


2 


116.077 


1.300.277 


Condition by Academic Learning Style 


18.941 


2 


9.471 


.106.899 


Condition by Introversion/ Extroversion 


.261 


1 


.261 


.003 .957 


Condition by Temperament Learning Style 


358.995 


3 


119.665 


1.340.266 


Error 


9109.254 102 


89.306 




Total 


266883.000 122 






Corrected Total 


10659.385 


121 







a R Squared = .123 (Adjusted R Squared - -.030) 

Male participants reported greater task development congruity (M = 34. 14, SD = 
8.32) with their facilitator in the face to face than in the computer-mediated sessions (M = 



94 

27.00, SD =8.63), by almost one standard deviation. This suggests that males were better 

able to define tasks needed to achieve their personal growth goals in the face-to-face 

condition than in the computer-mediated condition, a finding contrary to expectations. 

Female participants seem to develop tasks in collaboration with their facilitator equally 

well in either condition. (M = 23.49, SD = 8.93; M - 23.57, DS = 7.43) 

Table 10 Source table for dependent variable — Working Alliance Inventory (c) Task sub 
score 



Sources of Variance 



Type III Sum 
of Squares 



df 



Mean 
Square 



F Sig. 



Corrected Model 

Intercept 

Condition 

Gender 

Ethnicity 

Academic Learning Style 

Introversion/ Extraversion 

Temperament Learning Style 



Condition by Ethnicity 

Condition by Academic Learning Style 

Condition by Introversion/ Extraversion 

Condition by Temperament Learning Style 

Error 

Total 

Corrected Total 



1498.521 


19 


78.870 


1.158 


.308 


21142.080 


1 21142.080 310.493 


.000 


158.147 


1 


158.147 


2.323 


.131 


20.758 


1 


20.758 


.305 


.582 


60.911 


2 


30.455 


.447 


.641 


105.094 


2 


52.547 


.772 


.465 


114.795 


1 


114.795 


1.686 


.197 


26.789 


3 


8.930 


.131 


.941 


267.312 


I 


267.312 


3926 


HI 


130.877 


2 


65.438 


.961 


.386 


1.544 


2 


.772 


Oil 


.989 


65.358 


1 


65.358 


.960 


.330 


294.627 


3 


98.209 


1.442 


.235 


6945.380 102 


68.092 






34398.000 


122 








8443.902 


121 









a R Squared =177 (Adjusted R Squared = .024) 

Table 1 1 . Means and Standard Deviation -Dependent Variable, WAI (c) task sub score 
Independent Variable, Gender 





Male 




Female 




Face-to-face 




M =34.14 
S.D. = 8.32 




M =32.49 
S.D. = 8.93 


Computer-mediated 




M = 27.00 
S.D. = 8.63 




M =32.57 
S.D. = 7.43 



95 



Working Alliance Inventory client subscale goal 

There were no significant main effects or interactions for the dependent variable 
working alliance total, participant version. Table 12 lists relevant statistics. 
Table 12. Source table for dependent variable — WAI (c) Goal sub score 



Sources of Variance 




Type III Sum 
of Squares 


df 


Mean 
Square 


F 


Sig. 


Corrected Model 




1176.827 


19 


61.938 


.961 


.512 


Intercept 




12382.566 


1 12382.566192.211 


.000 


Condition 




105.700 


1 


105.700 


1.641 


.203 


Gender 




23.255 


1 


23.255 


.361 


.549 


Ethnicity 




14.336 


2 


7.168 


111 


.895 


Academic Learning Style 




161.415 


2 


80.707 


1.253 


.290 


Introversion/ Extraversion 




5.503 


1 


5.503 


.085 


.771 


Temperament Learning Style 




231.919 


3 


77.306 


1.200 


.314 


Condition by Gender 




90.501 


1 


90.501 


1.405 


.239 


Condition by Ethnicity 




102.026 


2 


51.013 


.792 


.456 


Condition by Academic Learning 


Style 


6.826 


2 


3.413 


.053 


.948 


Condition by Introversion/ Extraversion 


33.275 


1 


33.275 


.517 


.474 


Condition by Temperament Learning Style 


208.935 


3 


69.645 


1.081 


.361 


Error 




6571.010 


102 


64.422 






Total 




81420.000 


122 








Corrected Total 




7747.836 


121 









R Squared =152 (Adjusted R Squared = -.006) 



Facilitator Dependent Variable Analysis 
Facilitators completed the facilitator's version of the Working Alliance Inventory 
and of the Outcome Satisfaction Questionnaire. Unlike participants, the facilitators were 
not asked to report their predicted future use and computer/Internet skill and comfort 
levels in these surveys. Those factors were discussed at length in individual debriefing 
sessions with each facilitator, but do not appear in these analyses. 



96 

Outcome Satisfaction 

Facilitator scores on the Outcome Satisfaction measure demonstrated statistically 
significant for the main effect gender so follow up analysis was conducted. Table 10a 
displays the ANOVA outcome while Table 10b presents the means and standard 
deviation for the significant main effect. 

Facilitators reported that female participants experienced greater overall outcome 
satisfaction (mean 15.55, standard deviation 3.7) with their personal growth sessions than 
did male participants (mean 18.03, standard deviation 4.4). There was no significant 
interaction by condition suggesting that this facilitator perceived gender related outcome 
satisfaction did not differ by condition 

Facilitators perceived that female participants experienced greater outcome 
satisfaction with their personal growth sessions. However, there was no significant 
difference in participants' report of outcome satisfaction (see Table 5). 
Table 13. Source table for dependent variable — Outcome Satisfaction (facilitator) 



Sources of Variance 


Type III Sum 


df Mean Square 


F Sig. 




of Squares 


19 


17.831 




Corrected Model 


338.795 


1.140 .324 


Intercept 


6252.829 


1 


6252.829399.917 .000 


Condition 


3.410 


1 


3.410 


.218 .642 


^enii 


111.186 


1 


111.186 


7.111 .009 


Ethnicity 


.793 


2 


.397 


.025 .975 


Academic Learning Style 


22.924 


2 


11.462 


.733 .483 


Introversion/ Extraversion 


1.074E-02 


1 


1.074E-02 


.001 .979 


Temperament Learning Style 


23.115 


3 


7.705 


.493 .688 


Condition by Gender 


11.576 


1 


11.576 


.740 .392 


Condition by Ethnicity 


13.402 


2 


6.701 


.429 .653 


Condition by Academic Learning Style 


20.864 


2 


10.432 


.667 .515 


Condition by Introversion/ Extraversion 


27.036 


1 


27.036 


1.729 .192 


Condition by Temperament Learning Style 


65.180 


3 


21.727 


1.390 .250 


Error 


1563.530 100 


15.635 




Total 


32911.000 120 






Corrected Total 


1902.325 1 


19 







97 



Follow up analyses were conducted (Table 14) and found that facilitators felt that male 

participants experienced less outcome satisfaction (M ■» 18.03, SD =4.39) than did female 

participants (M = 15.55, SD = 3.70). 

Table 14 Means and Standard Deviation for gender variable 
Dependent Variable: Facilitator perceived outcome satisfaction 



GENDER 



Mean 



Std. Deviation 



Male 
Female 



18.03 
15.55 



4.387 
3.696 



Working Alliance Inventory total (therapist) 

Analysis of variance for dependent variable, working alliance inventory (f) total 
score, a composite of bond, task, and goal, produced significant the main effects for 



gender (F=7.11),p = .009). 

Table 1 5 . Source of Variance Table 
Inventory total (therapist) 



Dependent Variable: Working Alliance 



Sources of Variance 


Type III Sum 
of Squares 


df 


Mean 
Square 


F 


Sig. 


Corrected Model 


11899.169 


17 


699.951 


1.190 


.286 


Intercept 


223760.842 


1 


223760.842 380.508 


.000 


Condition 


1812.589 


1 


1812.589 


3.082 


.082 


Gender 


5178 639 


1 


5178.639 


8806 


.004 


Ethnicity 

Academic Learning Style 

Introversion/ Extraversion 


268.679 

20.833 

260.169 


2 

1 
1 


134.339 

20.833 

260.169 


.228 
.035 
.442 


.796 
.851 
.507 


Temperament Learning Style 

Condition by Gender 

Condition by Ethnicity 

Condition by Academic Learning Style 

Condition by Introversion/ Extraversion 


682.333 

1660.391 

552.180 

336.556 

.646 


3 
1 
2 
1 
1 


227.444 

1660.391 

276.090 

336.556 

.646 


.387 
2.824 
.469 
.572 
.001 


.763 
.096 
.627 
.451 
.974 


Condition by Temperament Learning Style 
Error 


1337.318 3 
60569.938103 


445.773 
588.058 


.758 


.520 


Total 


1195491.000121 








Corrected Total 


72469.107120 









98 

Working Alliance Inventory Bond (therapist) 

Table 17 shows that the gender variable produced a significant main effect in the 
facilitator scores for bond (F = 9.97,p = .002). Gender by condition was a significant 
interaction in the WAI (t) task sub score (F = 7.33, p = .008). The significant interaction 
between gender and condition in the facilitator version is on the sub scale bond. 

The Mean and Standard Deviation for the gender main effect is not reported 

because it is superceded by the significant gender by condition interaction presented in 

Table 18. Facilitators recognized a stronger sense of rapport on bond with female 

participants than they did with male participants. Since the participants, (Table 7), did 

not indicate any significance in the strength of bond developed it may be that the female 

participants were better able to communicate the sense of bond to their facilitator even 

though male participants seem to have experienced a similar level of bond. 

Table 16: Means and Standard Deviation for Main Effect Gender — Dependent Variable: 
Working Alliance Inventory (t) total 

Gender Mean Std. Deviation 

Male 83.83 34.118 
Female 100.28 19.303 

The interaction of gender by condition an important finding in this study that 
seeks to identify potential sources of individual differences that may impact the value of 
computer-mediated counseling and may be used as a screening factor. It would appear 
that male participants were better able to develop and communicate that development of 
rapport with their facilitator in the computer-mediated condition (M = 49.33, SD = 7.64) 
than in the face-to-face condition (M = 42.86, SD = 8.51), while female participants were 



99 



almost equally able to develop or communicate the development in either condition. This 

is consistent with the study hypotheses 

Table 17: Source table for dependent variable - Working Alliance Inventory bond (t) 



Sources of Variance 


Type III Sum of 
Squares 


df 


Mean 
Square 


F 


Sig. 


Corrected Model 


1251.611 


17 


73.624 


1.320 


.195 


Intercept 


63658.408 


163658.4081141.364 


.000 


Condition 


22.037 


1 


22.037 


.395 


.531 


Gender 


556.044 


1! 


556.044 


9:870 


.002 


Ethnicity 


49.859 


2 


24.930 


.447 


.641 


Academic Learning Style 


.181 


1 


.181 


.003 


.955 


Introversion/ Extraversion 


29.460 


1 


29.460 


.528 


.469 


Temperament Learning Style 


17.346 


3 


5.782 


.104 


.958 


Condition by Gender 


408880 


1 


408.880 


7.331 


.008 


Condition by Ethnicity 


97.366 


2 


48.683 


.873 


.421 


Condition by Academic Learning Style 


54.961 


1 


54.961 


.985 


.323 


Condition by Introversion/ Extraversion 


67.525 


1 


67.525 


1.211 


.274 


Condition by Temperament Learning Style 


54.236 


3 


18.079 


.324 


.808 


Error 


5744.720 


103 


55.774 






Total 


298400.000 


121 








Corrected Total 


6996.331 


120 









a R Squared = .179 (Adjusted R Squared = .043) 

Table 18 Mean and standard deviation for gender by condition interaction 
Dependent Variable: Working Alliance Inventory (t) bond 



Male 



Female 



Face to Face 



Computer Mediated 



Mean= 42.86 


Mean = 51.66 


s.d. = 8.51 


s.d. = 6.69 


Mean = 49.33 


Mean = 48.69 


s.d. = 7.64 


s.d.= 7.27 



Working Alliance Inventory Task (therapist) 

Analysis of the WAI (t) task sub score resulted in two significant main effects, 
condition (F = 4.81, p = .03) and gender (F = 5.87, p = .02). Facilitators reported more 
collaborative task development with female participants than they did with male 



100 



participants. Note that the participants did not indicate any significant main effect (see 
Table 10) for task development however their responses did produce a significant 
interaction (see Table 1 1) for gender by condition not found in the facilitator scores. 
Table 19 Source table for dependent variable — Working Alliance Inventory (t) task 



Sources of Variance 


Type III Sum 
of Squares 


df 


Mean 
Square 


FSig. 


Corrected Model 


1796.808 


17 


105.695 


1.342.182 


Intercept 


18699.182 


1 


18699.182 


237.440 .000 


Condition 


378.907 


1 


378.907 


4.811.031 


Gender 


463.005 


1 


463.005 


5.879.017 


Ethnicity 


14.136 


2 


7.068 


.090.914 


Academic Learning Style 


3.797 


1 


3.797 


.048 .827 


Introversion/ Extraversion 


26.073 


1 


26.073 


.331.566 


Temperament Learning Style 


209.490 


3 


69.830 


.887.451 


Condition by Gender 


63.889 


1 


63.889 


.811.370 


Condition by Ethnicity 


230.013 


2 


115.006 


1.460.237 


Condition by Academic Learning Style 


134.671 


1 


134.671 


1.710.194 


Condition by Introversion/ Extraversion 


27.713 


1 


27.713 


.352.554 


Condition by Temperament Learning Style 


281.066 


3 


93.689 


1.190.317 


Error 


8111.606 103 


78.753 




Total 


106234.000 121 






Corrected Total 


9908.413 


120 







a R Squared = .181 (Adjusted R Squared = .046) 

Table 20: Means and Standard Deviation for gender variable 
Dependent Variable: Working Alliance Inventory® task (therapist) 



Gender 



Mean 



Std. Deviation 



Male 
Female 



23.97 
29.55 



12.774 
7.149 



Facilitators also noted stronger task collaboration in the computer-mediated 
condition than in the face-to-face condition. It is intriguing that both facilitators and 
participants reported gender differential in this dependent variable although they did not 
identify it in the same manner. Gender clearly is a factor which influences process and 
outcome efficacy in computer-mediated sessions. 



101 



Table 21 Means and Standard Deviation for condition variable 
Dependent Variable: Working Alliance Inventory task (therapist) 



Condition 



Mean 



Std. Deviation 



Face to face 
Computer mediated 



27.74 
28.65 



9.049 
9.172 



Working Alliance Inventory Goal (therapist) 

Again, as in the task sub scale, the facilitators reported significant main effects for 

the variables condition (F - 4.01, p = .048) and gender (F= 7.34, p « .008) in the goal sub 

scale (Table 22). Means and standard deviation for condition and for gender are reported 

in Table 23. 

Table 22 Tests of Between-Subjects Effects 

Dependent Variable: Working Alliance Inventory goal (therapist) 



Sources of Variance 



Type 



II Sum of 
Squares 



df 



Mean 
Square 



F Sig. 



Corrected Model 
Intercept 



2412.598 
7347.594 



17 141.918 
1 7347.594 



Ethnicity 

Academic Learning Style 
Introversion/ Extraversion 
Temperament Learning Style 
Condition by Gender 

Condition by Ethnicity 

Condition by Academic Learning Style 

Condition by Introversion/ Extraversion 

Condition by Temperament Learning Style 

Error 

Total 

Corrected Total 




318.927 

186.915 

6.964 

468.334 

10422.757 
57318.000 
12835.355 




120 



a R Squared =188 (Adjusted R Squared = .054) 

Female participants were perceived to have or at least to have communicated 
greater session goal definition (M=20.72, SD ■ 8.48) than did males participants 
(M-14.28, SD =13.86) 






102 

Table 23: Means and Standard Deviation for gender variable 
Dependent Variable: Working Alliance Inventory goal (therapist) 

Gender Mean Std. Deviation 

Male 14.28 13.864 

Female 20.72 8.477 

Facilitators thought that participants, regardless of individual difference, showed 

greater abilities to formulate and define goals in the computer-mediated condition (M = 

19.75, SD =10. 17) than in the face-to-face condition (M=18.74, SD = 10.60). Goal 

definition is extremely important in evaluating efficacy because unless the goal is rather 

specific it is difficult to assess its achievement. 

Table 24 Means and Standard Deviation for independent variable condition, dependent 
Variable: Working Alliance Inventory goal (therapist) 

Condition Mean Std. Deviation 

Face to face 18.74 10.597 

Computer mediated 19.57 10.171 

In summary, condition, gender, and academic learning style were the independent 
variables that showed statistically significant main effects in the scales evaluated. 
Gender by condition was the only significant interaction and occurred in both participant 
and facilitator measures. From the participants' perspective, visual learners predicted 
greater likelihood of seeking computer-mediated mental health services if they a re 
needed in the future than did verbal learners. Paradoxically, verbal learners indicated that 
they had greater computer and Internet skills than did visual learners. Participants' 
responses indicated that males were better able to collaboratively develop tasks with their 
facilitators to use to achieve their personal growth goal in the computer-mediated 



103 

condition than in the face-to-face condition. Females were able to develop tasks equally 
well in either condition. 

From the facilitators' point of view, female participants were better able to 
develop an overall working alliance, than males. Female were better able to collaborative 
develop goal oriented tasks, than males (perhaps because they were equally good at 
developing task in each condition). Females were better able to define their goal for the 
personal growth sessions. There were significant findings for experimental condition. 
Males were better able to develop a bond with their facilitators in the computer-mediated 
condition. Task development was better achieved in the computer-mediated condition. 
Goal definition was more precise in the computer-mediated condition. While the 
evidence is not definitive, it is certainly consistent enough to suggest that individual 
differences do contribute to counseling process and outcome efficacy and should be 
further investigated. 
Qualitative Analysis 

Comprehensive qualitative analysis of the data collected is outside the scope of 
this project. However, some material is presented to illustrate and confirm the constructs 
presented in Chapter 2 - presence, trustworthiness, and intimacy. Some participants 
expressed positive reactions to their experiences in the computer-mediated condition. 
Comments from participants are replicated without change except when it was necessary 
to replace the facilitator's name With facilitator in two comments. Grammar and spelling 
are explicitly overlooked for the sake of spontaneous communication during a session 
therefore those "errors" remain in the survey comments. The surveys were all completed 
on the Internet, and participants reasonably responded with the same disregard for writing 
mechanics as those in the computer sessions has been instructed to do. 



104 



Presence — "It was cool to be able to just log online to talk, it was easily 
accessible, but instant messages sometimes lack tone of voice that can 
make it more difficult to understand the subtleties or conversation, plus, 
in some ways the annonymity of doing it over the computer was nice, i 
could cry or whatever without feeling watched and i could talk from the 
privacy of my own home that was both good and bad, good cause it was a 
comfortable place, bad because afterwards i couldn't leave some . . ." 

Trustworthiness — "I just really realized how helpful it is to talk to 
someone who is totally objective and knows nothing, or has made no 
judgments, about you. It was really cool to have facilitator because he 
went through some of the problems that I am going through right now, and 
he was able to disclose his experience with me and make me feel better 
about my decisions" 

Intimacy — I feel that using the computer was nice, it gave you a way to 
communicate, without feeling self conscious about what was being said" 



Other students were less happy with their computer-mediated experience. 

Presence — "I think this is great to look at. However, I feel that the 
computer is an inefficient way to communicate thoughts to another person 
due to the ambiguous nature of the internet" 

"Having the counseling sessions over the computer made it seem as if we 
were wasting some of our time. There was sometimes a lag in the chat 
room, and I would often sit waiting to see what the facilitator had to say. I 
feel that the sessions might have been more productive in person. Further, 
I did not feel very comfortable having to type my feelings on the 
computer. It was a bit strange having to type "I am smiling" "I am 
laughing", ect" 

"I did not like the internet sessions that much because I tended to forget to 
sign on line. If I had an appointment to go to I feel that I would remember 
better. Also, you could not see facial expressions or how the other person 
was feeling at the time. This is hard when you are" 

"There were times that I didn't know how to put what I felt into words. I 
feel that if I had been in an actual office with a therapist they may have 
been able to lead me through my feelings and putting them into words. I 
think that when it comes down to it a person needs the one on one that an 
in office session gives." 

Trustworthiness — " The computer is not always reliable and to think that 
therapy will be given through the internet is depressing" 



105 



Intimacy — "not getting the comfort of being in the same room as 
someone who is listening and caring" 

Ambivalent responses included: 

"Facilitator was very good and I felt very comfortable with her. I think I 
would have preferred to be in-person though." 

"When online with your therapist you never know what they are doing, 
thinking or saying at that moment. Being online takes away the personal 
aspect of it. However, I do think that the computer sessions would be a 
good back up like if the person had to go out of town on business or 
something" 

Some participants offered observations about the mechanics of Internet counseling that 
can get in the way of counseling. 

"Most people think faster than they can type so it can be frustrating in the 
chat rooms at times. You have a lot to say but it takes a long time to get it 
out. Much different than talking on the phone or in person" 

"Having to type stories that are really long" 

" I had some distractions in my room when we were talking." 

"it felt like a lot of time was wasted waiting for messages to go back and 
forth cause i was using my home dial-up computer that is sometimes alot 
slower than a T3 or dsl connection" 



CHAPTER 5 
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 

The purpose of this study was to explore the efficacy of Internet counseling and 
the impact of individual differences on that efficacy. This chapter summarizes the study, 
discusses the results and offers conclusions, and recommendations for further study. 

Summary of the Study 

This study was conducted in Florida with undergraduate student participants and 
graduate student facilitators from a university and a community college in the same 
municipality. One hundred and twenty one students volunteered to participant in three 
personal growth sessions and completed the sessions and five surveys (demographics, 
learning style, personality traits, working alliance, and outcome satisfaction). They were 
randomly assigned to either the face-to-face or the computer-mediated condition. The ten 
counseling graduate student facilitators were trained and provided with a detailed 
procedure manual and report forms. Each facilitator worked with an equal number of 
students in each condition. Analyses of Variance were conducted using individual 
differences - gender, ethnicity, learning style, and personality traits as the independent 
variables. Follow up tests were conducted to analyze variables that demonstrated a 
significant main effect or interactions. 

Conclusions 

Six hypotheses were examined and the results will be discussed individually. 
Hypothesis I . . The null hypothesis that there is no difference between face-to-face and 

106 



107 

computer-mediated counseling when process factors are compared was partially 
disproved with regard to gender, task and bond. 

Hypothesis II The null hypothesis that there is no difference between face-to-face and 
computer-mediated counseling when outcome satisfaction is compared was disproved for 
gender as viewed by the facilitator. 

Hypothesis III The hypothesis that a gender differential affects efficacy in counseling in 
general and between face-to-face and computer-mediated counseling was supported on 
several measures. From the facilitators' perspective, gender affected outcome 
satisfaction, with men reporting greater outcome satisfaction regardless of condition and 
greater task congruity with their facilitators in the face-to-face condition. This is contrary 
to expectation because the previous research literature suggested that men are less willing 
to seeking counseling. Therefore, it was hypothesized that males would be more 
comfortable with and more successful in the computer-mediated condition. Results of 
this study suggest that although men are less likely to seek counseling as previously 
reported, when they do seek counseling they prefer it to be face-to-face. 

The study indicated that males were less willing to engage in even mild 
counseling or personal growth sessions than females, even when extra credit in their class 
was offered. Eighty eight males initially expressed interest by completing the contact 
sheet and informed consent during the classroom recruitment, however only twenty nine 
or 33 percent actually participated and completed the project in contrast to 42 percent of 
females. Peer pressure may have led students to sign up for the project in the presence of 
their instructor and classmates but to decline when individually contacted. Regardless of 
influences on participation and completion, males consistently produced results 



108 

indicating that gender is a significant individual difference in predicting face-to-face or 
computer-mediated success. 

Hypothesis IV. The hypothesis that there is no interaction between ethnicity and efficacy 
in either condition could not be disproved in this study design although the relatively 
literature on multi cultural counseling suggests that race and ethnicity are important 
enough issues to warrant further research with a different design or different process and 
outcome measures. 

Hypothesis V : The hypothesis that learning style differentially affects efficacy in 
counseling in general and between face-to-face and computer-mediated counseling was 
supported for prediction of future use of computer-mediated mental health services. 
Hypothesis VI: The hypothesis that there is no interaction between personality attitude 
(introversion/extraversion) and efficacy in either condition could not be disproved in this 
study design although the qualitative evidence in the relevant literature suggests that this 
variable is important enough to warrant further research with a different design or 
different process and outcome measures 

Limitations. 
The major limitations of the study were the age and subculture homogeneity of 
the participant population, and the acuity of the dependent variables. The participants 
were young adults living in a rich, mobile cultural environment of college campuses. The 
counseling and guidance resources were multiple and readily available (Counseling 
Center, Infirmary, Student Services, Resident Advisors, Activities Advisors, Coaches, 
Professors, and such) whereas Internet counseling is seen as most applicable to those with 
limited resources and access to mental health care. While this study did provide some 
significant results with the population involved, additional research is needed with 



109 

clinical populations, and geographically or situationally remote populations who have 
greater dependence on telecommunication for health care. 

In retrospect, a survey measure should have been developed to appraise the 
participants' current Internet usage. Areas to be assessed would include type of Internet 
provider service (IPS), number and names of listserv membership, number and name of 
use group memberships, frequency of chat room use, frequency of bulletin board use, 
number and nature of (personal, vendors, business) email use, knowledge about and use 
of search engines. It is an adage of social psychology that the best predictor of future 
behavior is current behavior, therefore it would be instructive to see how the participants 
are currently using the Internet rather than or in addition to asking them to predict future 
use of Internet counseling, as was done is the outcome satisfaction questionnaire. It is 
assumed that the computer and Internet competence of this sample population is probably 
greater than that of the general American population and population of potential clients. 

Brief therapy and 50-minute therapy sessions have been demonstrated to be 
effective in face-to-face counseling. However, these time frames may or may not be 
equally effective in Internet counseling because speaking is generally accomplished faster 
than typing. If a person has difficulty producing speech, it is probably part of the 
problem for that he or she is seeking help. The same is not true if a person has difficulty 
typing quickly, concisely and/or correctly. Dial up ISPs have an annoying habit of 
disconnecting that steals precious time from a session. In this study, the time frame was 
held constant for the two conditions. This may have compromised the effectiveness of 
the Internet condition. 



110 

Implications and Recommendations 
Research 

The obvious implication of this study is that computer-mediated counseling is a 
viable mode for providing mental health services, and in some dimensions surpasses 
face-to-face counseling in effectiveness. Furthermore, there is s preliminary evidence 
that there are significant individual differences that need to be explored to determine who 
is most likely to benefit from computer-mediated counseling and who should be referred 
to face-to-face counseling. The suitability of a potential client and the appropriateness of 
computer-mediated 

With research-based information, including results in this study, screening 
procedures can be developed that consider not just the presented problem but also the 
characteristics of the client who is seeking computer-mediated mental health services. 
When potential clients have a choice of service modalities, one size does not fit all. 
Isolated clients, however, may not have a choice of services. For these clients, the 
therapist's awareness of individual differences can be used to maximize the effectiveness 
of computer-mediated counseling even when in the best of all possible situations, face-to- 
face counseling may have been ideal. 

This study addressed only individual counseling. Research must be designed and 
conducted to evaluate the potential for Internet group therapy, that actually appears to be 
the most prevalent format in current usage. 

The issues presented in the personal growth sessions conducted for this study 
were valid and legitimate concerns and most students felt that they genuinely benefited 
from the experience even when their original motive was extra credit, rapport with the 
classroom instructor, or altruistic desire to help and be a part of research. The nature of 



Ill 

these issues did lead to referral to formal University or College counseling resources. 
Nonetheless, persons motivated to locate and pay for Internet counseling will presumably 
be experiencing more serious problems, have fewer personal coping resources, and/or a 
greater perceived need for services. The results of this study may or may not generalize 
to the population most likely to use Internet services. Further study must incorporate this 
population. A study of a clinical population could use any of a number of more 
objective, statistically validated outcome measures discussed in chapter 2 of this paper. 
Clinical 

College students were willing to discuss serious personal growth issues over the 
Internet with a facilitator they had never met. They had certain assurances, to be sure, 
including but not limited to a copy of the Institutional Review Board contact phone 
number and email address. They met with the principal researcher in person when she 
recruited in their classroom. They had access to the department and the dissertation 
committee chairperson through their classroom instructor. They were advised of the 
specific campus resources available to them as students, should their issues require crises, 
counseling, psychological or psychiatric intervention. People without these immediate 
and serious recourses also seem to be willing to disclose private intimate information 
over the Internet. Given the number of counseling web site that exist, clinicians must 
provide protection for vulnerable clients and must also consider ways to protect their own 
professional integrity. Students did not ask if the project was safe and approved by the 
University, they were given specific documentation that described their responsibilities, 
protection, resources, and recourses. The Web counselor should be expected to provide 
the same information to potential clients. 



112 

This research indicates that gender and academic learning style affects the 
efficacy of counseling. Web clinicians should consider incorporating this information 
into suitable screening procedure. There are certainly more critical issues to be included 
in screening such as emergency access phone numbers, medication (as an indicator of 
seriousness and 'doctor' shopping), however it should be disclosed to males seeking 
Internet counseling that "research suggests that" they might have better results with face- 

» 

to-face counseling if that is an option for them. Males should certainly not be excluded 
from computer-mediated counseling on the bases of this research. 

Academic learning style is likely to be a factor that pre-selects those who seeking 
Internet counseling since it was found to be significant in measures of predicted future 
use and computer comfort and skill. 

Because computer-mediated counseling is often suggested as particularly 
applicable for persons with disabilities, follow up research should be designed to 
compare keyboarded computer-mediated counseling and voice activated computer- 
mediated counseling. Even persons with disabilities who are not currently using voice 
activate computer access might be encouraged to do so if research bears out its benefit. 
Personal voice activate software has become cheaper than one traditional therapy session 
and might be provided by a third party payer in a 'medical needs' situation. 

The code of ethics of Certified Rehabilitation Counseling (2002) is being revised 
and extended to include "Electronic Communication and Emerging Applications," 
section I addressing communication and the counseling relationship. The results of this 
research indicated that section 12-B h. Inappropriate Use should be expanded to include 
some recognition that individual differences may be include in this category as well as 



113 

'presenting problems' already include in this article of the code. The NBCC (2001) 
ethics for the practice of Internet counseling includes a section entitled Internet 
Counseling Relationship which offered direction for dealing with suspected 'imposter' 
clients and minors. The board should consider adding a item in this section about 
individual differences, known and yet to be identified. 

Internet counseling exists. As the professional associations struggle with 
developing working papers and preliminary ethical guidelines, the research community 
can provide the data needed to advise these decisions. Clinicians must practice well and 
ethically to set the tone and expectations for this new frontier in mental health service. 

This study begins to explore the personal characteristics that can be used in 
potential screening for appropriateness of Internet services for a given client or 
population of clients, or in the absence of clear cut reasons to pre screen, can be used to 
advise the therapist to insure that the differential potentials are considered. The core 
issues remain to be investigated more thoroughly - efficacy of Internet counseling, 
format and restrictions to maximize efficacy, and individual differences of potential uses 
that can enhance or limit outcome results and satisfaction. 



APPENDIX A 
FORMS AND INSTRUMENTS 

Research Participant Information Sheet 



This information is strictly confidential and will be used only for purposes of this study 
including contacting the participant to schedule sessions, allow reporting to instructors 
for purposes of class credit where it is offered, demographics of study, and such. 

Date: 



Name: 

E-mail Address: 

Local Phone number: 

Age: 

Level freshman 



Gender: 
sophomore 






Race(s): 
junior senior 



Major: 



Instructor: 



Class: 



Best day of week to schedule study sessions: 
Best time of day morning 



M 



TU 



W 



TH 



afternoon 



evening 



Disability accommodations needed (specify) Contact Information Sheet with 
demographic information 



Informed Consent 



Project Title: Process and Outcome efficacy of 21 st Century Counseling Techniques 

Please read this consent document carefully before you decide to participate in this 
study 

Purpose of the research study: 



114 



115 



The purpose of this doctoral dissertation study is to compare how students feel 
about his or her experience of personal growth sessions dealing with common issues 
faced by young adults. 

What you will be asked to do in the study: 

You will be asked to talk about issues that concern you such as adjustment to 
college life, relationship with room mate, adjustment to study demands, time 
management, stress management and such. You will be asked to participate in three one- 
hour sessions with a research assistant. You will be randomly assigned to participate in 
these three personal growth sessions in person or via computer. That is, you will either 
be assigned to three computer sessions or three face-to-face sessions. You will be 
working with one person, a graduate student in counseling for all three sessions. The 
graduate counseling student will not be the primary investigator. After the 3 rd session 
you will be asked to complete five (5) pencil and paper surveys so the last session will 
require one hour for your personal discussion and one hour to complete the surveys. 

Time required: 

4 hours 

Risks and benefits: 

You will receive three hours of individual personal growth guidance in working 
with a personal growth issue of concern to you. You may become distressed and decide 
that you need counseling that is available to you at the University Counseling Center. 

Compensation: 

You may receive extra credit in the course from that you were recruited if the 
professor offers it. If this credit is available, it will be no more than 2% of the course 
point value. The investigator has no control over the awarding of points. If the professor 
offers points, you will receive them whether you complete the study or not. 

Confidentiality: 

Your identity will be kept confidential to the extent provided by law. Your 
information will be assigned a code number. The list connecting your name to this 
number will be kept in a locked file in my faculty supervisor's office. When this study is 
completed and the data have been analyzed, the list will be destroyed. Your name will 
not be used in any report. Your professor will be provided with a list of students who 
volunteered if you are to receive credit but he/she will not receive any information about 
your participation nor whether you completed the study. If you are assigned to the 
computer-mediated condition, you will be working on a secure (log-on, password, and 
firewall encryptions) web site, however there is a small chance that it could be 



116 



compromised. The study results will be published as a dissertation and available in the 
University of Florida George A. Smathers Library after it has been completed. 

Voluntary participation: 

Your participation in this study is completely voluntary. There is no penalty for not 
participating. There is no penalty for deciding to withdraw from the study at any time. 

Right to withdraw from the study: 

You have the right to withdraw from the study at any time without consequence. 

Whom to contact if you have questions about the study 

Martha L. Groble, graduate student, Department of Counselor Education 

Martye@att.net 

(904) 387-2617 

James Archer Jr, PhD, College of Education, Department of Counselor Education 

Jarcher@coe.ufl.edu 

(352) 392-0732 extension 231 

Whom to contact about your rights as a research participant in this study: 

UFIRB Office, Box 1 12250, University of Florida, Gainesville, FL 3261 1-2250 
(352) 392-0433 

Agreement: 

I have read the procedure described above. I voluntarily agree to participate in the 
procedure and I have received a copy of this description. 



Participant: Date: 

Principal Investigator: Date: 



117 

Outcome Satisfaction Questionnaire (participant form) 

NB: This instrument was administered online in the WebCT survey function using an 

Software application, Respondus, so the participant view varied from this. They marked 

their responses by clicking in the appropriate radio button or text box, not depicted 

below. 

Question 1 The skills, abilities, and experiences that I learned directly enabled me to 
reach the personal growth goal I set for these sessions. 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 2 Being able to apply the skills, abilities, and experiences I gained in these 
sessions to resolve other stresses and concerns in my life. 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 3 The amount of information my facilitator gave me about my particular stress, 
concern, or problem. 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 4 The amount of information my facilitator gave me about my mental wellness 
practice. 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 5 The relief from the stress or concern that these sessions provided. 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 6 Overall rating of my facilitator. 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 7 Overall rating of my personal growth session 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 8 How would you rate your computer skills (e.g., keyboarding, word 
processing) and comfort? 

Computer guru good user skills adequate user skills novice skills computer phobic 



118 



Question 9 How would you rate your Internet skills? 

Internet guru good user skills adequate user skills novice skills Internet phobic 

Question 10 Please tell us what you liked least about this experience. 

Question 1 1 Do you have observations, reflections or comments, that have not been 
addressed in these surveys, that you wish to share about being part of this study? 

Question 12 How likely are you to choose computer mediated counseling should you 
choose counseling at some time in the future? 

Very likely likely not likely would not not sure 

Outcome Satisfaction Questionnaire (facilitator form) 

NB: This instrument was administered online in the WebCT survey function 

using an application, Respondus, so the facilitator view varied from this. They 

marked their responses by clicking in the appropriate radio button or text box, not 

depicted below. The participant link was labeled Outcome Satisfaction Questionnaire but 

the facilitator link was labeled Facilitator Survey 1 because all surveys were listed on the 

same screen. It was a concern that the participants might try to second guess their 

facilitators rather than offer their own frank opinions, if they knew they were completing 

similar surveys. The same convention was used with the Working Alliance Inventory 

label for participants and Facilitator Survey 2 label for facilitators. 

Question 1 participant ID and facilitator initials 

Question 2 The skills, abilities, and experiences that this participant learned directly 
enabled him or her to reach the personal growth goal set for these sessions. 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 3 Participant being able to apply the skills, abilities and experiences gained in 
these sessions to resolve other stresses and concerns in life. 



119 



extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 4 The amount of information I gave this participant about his/her particular 
stress, concern or problem. 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 5 The amount of information I gave this participant about mental wellness 
practice. 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 6 The relief from the stress or concern that these sessions provided this 
participant. 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 7 Overall rating estimate of this participant's reaction to me. 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 

Question 8 Overall rating estimate this participant's growth sessions 

extremely satisfied very satisfied satisfied not very satisfied not at all satisfied 






APPENDIX B 
FACILITATOR TRAINING MANUAL 

Table of Contents 



1 . Logistics 

2. Procedure section of dissertation proposal with protocol for each session 

3. Record forms 

4. WebCT access information with copy of each screen from http to chat room 

5. Brief Cognitive Behavior therapy material from Meichenbaum 

6. Computer Counseling Technique (articles listed in required reading) 

7. College Student Personal Growth Issues (articles listed in required reading) 

Front pocket 

Treatment plan forms 
Progress notes forms 
Back pocket 

Facilitator checklist 



Contacts: Martye Groble Martve(g>.att.net C904^ 387-261 7 

Loren Groble Groble Robert@.hotmail. com (352) 335-01 18 
(your local all-purpose helper) 

James Archer Jr. Jarcher(q),coe.ufl . edu 
(dissertation committee chairman) 



120 



121 
Logistics 

Recruiting Participants: 

Researcher contacts instructors of undergraduate classes and get permission to 
recruit in their classes. Researcher recruits in classes giving brief description and having 
volunteers fill out a contact sheet and a signed consent. The volunteer is also given a 
copy of the informed consent. 
Scheduling Participants: 

Researcher or trained assistant will randomly assign the participant to one 
condition or the other. XXX will assign the code (to keep things simple since he has 
already begun facilitating). The code takes the form of two or three letters (the initials of 
the classroom instructor), four digits (unique ID), and two letters (facilitator's initials). 
Therefore, LMCxxxxDP is a student in Laura's class with Dan for a facilitator. Use the 
code not the participants' name on all paperwork and tapes. Once you have the contact 
sheet, contact your participant and arrange a mutually agreed upon time to meet. Be 
prompt or early. Record all contact and results on your tracking sheet (especially 
answering machine messages and no shows). 

FACE to FACE CONDITION The facilitator will contact the counselor education office 
to schedule a room for the face-to-face session. The facilitator will meet the participant 
outside the lab area, introduce him or herself and lead the participant to the assigned 
room (rooms will change with each appointment due to availability). Be sure you have 
gotten the key from the office, unlocked the room and checked for ftirniture placement 
and cleanliness before the participant arrives. These sessions are to be taped to keep the 
conditions equal and to evaluate adherence to protocol. Tapes will be provided. Let me 



122 

know what size you need for your recorder. If you do not have a recorder, one will be 
provided for the duration of the experiment. Session should last 50-60 minutes. If the 
session is shorter or longer than the norm, please make a note why. It is fine; I just need 
to know why. Tapes, clocks, tissue, manila envelopes and any new handouts will be in 
the team mailbox so please check it regularly. If you leave materials be sure they are in 
sealed envelopes for privacy, 

COMPUTER-MEDIATED CONDITION Entering your participant into the WebCT 
system is a two part process. Each participant has the last name Participant, and the first 
name alphanumeric code - because these show up in the chat room. Do not use the 
participant's name. Use the code for the password to keep things simple and private. 
Use the code plus the numeral 1 to create a second account where you can complete the 
facilitator surveys for this participant (Your regular access level is TA and as such you 
can see but not do the surveys). WebCT automatically stores all dialogues so this privacy 
is paramount. If your participant already has a Global ID from another class, he or she 
must not use it for this study because it would be recorded. 

The chat room format in WebCT is designed for class access, not individual 
access therefore a participant might enter your session. Please be very assertive in asking 
them to leave and return at their scheduled time. Checking the chime entry box will help 
you notice if someone does accidentally enter. I do not anticipate this being a problem 
but be aware it could occur and be prepared to handle it. If two facilitators have 
scheduled a chat room for the same time, one should move to any empty chat room 1-4. 
Please do not use 5 or 6 with participants except as noted below. 



123 

I will work with each facilitator to insure that you are comfortable using WebCT, 
working to the session room and helping your participants get there as well 
( Martye@att.net) . You can always get help from the university help desk 392-help for 
login problems. Be sure you have these worked out for yourself and for your participant 
before your first scheduled personal growth session. For big problems, Doug Johnson is 
a very user-friendly administrator of WebCT and you can reach him through the CIRCA 
help desk. Be sure to mention that project you are with when you leave him a voice 
message. 

We are only using rooms 1 through 4 for participants, however I would like to 
schedule facilitator meetings with me in the general chat for dissertation room and you 
may use the General Chat for all rooms to consult with one another (but not with 
participants). The assessment tech will wait in room 5 during CMC administrations to 
answer any question or help the participant. 
STUDY MEASURES 

The facilitator fills out two measures at the end of the third session. The participant will 
fill out four measures at the end of that session. Administration will be conducted by 
Loren so please give him your schedule of the last sessions so he can be present at the 
proper time to conduct the assessments. 
TAPES AND RECORDS 

When you have completed the entire process with a participant return tapes, treatment 
plans, contact sheets, progress notes, and so forth to me. Turn in tracking sheets by email 
weekly so we can keep track. 



124 

Session Structure Guidelines 

Condition 1 Face-to-face 

Session 1 Face-to-Face: 60 minutes 

Goals: To engage the participant in collaborative, cognitive personal growth counseling 

Objectives: To develop rapport with the participant 
To clarify the therapy process to be used 
To identify and clarify the participants issue-based goal 
To collaboratively develop a set of tasks to accomplish the goal 

Session 1 : The facilitator will welcome the participant and answer any questions. 

The purpose of the first meeting is to begin to establish a bond between the facilitator and 

the participant, explain the nature, language and methods of the CBT sessions, identify 

the goals and tasks to be accomplished and make the next appointment. For face-to-face 

sessions this means discussing therapy conventions of freeze frame, stop action, focus on 

here and now, and other as listed in the training manual. For the computer-mediated 

sessions, the focus on here and now, cognitive refraining and homework are similar to the 

face-to-face session, however the subtle therapeutic interventions will differ in that rather 

than non verbal vocalizations, facial expression, body language and visual/spatial 

environment the action literally in the face-to-face session, the research assistant will 

teach and use bracketed emotions, descriptive immediacy, and textual visualization. The 

participant will need to practice these with the research assistant prior to the experiment 

until he is comfortable and confident using them. 

Session 2 Face-to-Face: 60 minutes 

Goals: To continue to build rapport and to process work to date 

Objectives: To continue to develop rapport with the participant 
To review independent participant work to date 
To process experiences relevant to tasks and goals since last session 



125 

To collaboratively revise, enhance, or focus the set of tasks to accomplish 
the goal 

Session 2: The facilitator will welcome the participant, ask about the homework 

and tasks completed during the past two weeks since the first session, review work 

accomplished and work not accomplished. Review the goal and tasks to accomplish that 

goal. Discuss progress and obstacles to success. Plan tasks for next two weeks. 

Session 3 a Face-to-face 

Goals: To review work of three sessions and bring about satisfactory closure 

Objectives: To continue to develop rapport with the participant 
To review independent participant work to date 
To process experiences relevant to task and goal since last session 
To highlight gains made during therapy 
To plan ongoing self help tasks 
To bring about satisfactory closure and make referral is necessary. 

Session 3a: The facilitator will welcome the participant and work through closure 

and termination activities with participant, review progress, homework accomplished and 

not, and plan for the participant's further self help. 

Session 3b Face-to-face 

Goals: To evaluate the working alliance, outcome satisfaction and individual differences 
of the participants. 

Objectives: To continue to develop rapport with the participant 
To administer the evaluation instruments 
To thank the students for their participation 

Session 3b: The facilitator escorts the participant to the computer lab, helps them 

log on, make sure the tech is in the help chat room, and give the student the laminated 

cards to help with the session. The facilitator will complete the WAI - T, his or her 

assessment of the therapeutic relationship. 

Computer-mediated Sessions are similar with the following exceptions 



126 

Session 1 Computer-mediated 

Goals: To engage the participant in collaborative, cognitive personal growth session 

Objectives: To develop rapport with the participant 
To clarify the therapy process to be used 
To teach text-talk non verbal techniques 
To identify and clarify the participants issue-based goal 
To collaboratively develop a set of tasks to accomplish the goal 

Session 3b Computer-mediated 

To continue to develop rapport with the participant 

To guide the participant to the survey section of WebCT and verify that 

the tech is in the help chat room 

To thank the students for their participation 



127 



Therapy Plan and Progress Notes 



Plan 



Participant ID: 



Counselor ID: 

Condition: 



Date: 



Presenting Issues(s): 
Participant Strengths: 



Resources: 



Goal(s): 



Ways to reach goal: 
Session 2 and 3 
Participant ED 



Facilitator ID 



Condition 



Progress Notes (date each entry) 



128 



Facilitator Checklist 
Participant ID Facilitator initials Instructor 

1 . get contact sheet that has been coded and assigned to a condition 

2. contact participant and set up first appointment 

3. _____ contact department secretary to reserve a room for F2F sessions 

OR 

contact the participant and instruct on the WebCT log-on procedure 



prior to the first CMC session 

_ check tape and recorder for F2F condition, call helper if you need either 



at 355-0118 

5. conduct session 

6. schedule next session 

7. repeat 2 through 6 above 

8. contact and schedule assessment tech to be present in person or on-line 

during assessments 

9. conduct final session 

10. introduce participant to assessment process and tech 

1 1 . complete the WAI (t) and the OSQ (f) for this set of sessions 

12. put all three tapes, treatment plans and progress notes in manila 

envelope, label with the participant's code in the top left corner and put in team 
box or contact helper for pick up 



129 
Sample of tracking sheet 

Tracking record of all volunteers regardless of degree of completion. This record 
is meant to account for each volunteer. Fill in the code ID for each volunteer whether 
they actually participate or not. Indicate F2F or CMC under condition. Put a check mark 
under each session completed. Use the note column to mention anything usually (eg. The 
woman who never intended to participate). We need each record so we can determine 
drop out rate and such. 



Participant Facilitator^ 3 ^ 



# # Partici D ant Nbr Notes ' 

w * Kamc,pant Facilitatorcomments 

sessions surveys 

complete complete ^j^ 



LMC0001 


Dan 


X 












LMC0002 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0003 


Dan 


X 












LMC0004 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0005 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0006 


Dan 


X 












LMC0007 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0008 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0009 


Dan 


X 












LMC0010 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0011 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0012 


Dan 


X 












LMC0013 


Dan 


X 


X 


1 




scheduled 


LMC0014 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0015 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0016 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0017 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0018 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0019 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0020 


Dan 


X 












LMC0021 


Dan 


X 


X 


3 


4 


2 


finished 


LMC0022 


Dan 


X 












LMC0023 


Dan 


X 








dropped 


LMC0024 


Dan 


X 












LMC0025 


Dan 


X 


X 


3 


4 


2 


finished 


Sample Screen Shot training pages 











130 

WebCT Samples Screens 
Checking your participants survey status. With TA level WEBCT access you can 
check the status of your participants and know who has completed their surveys and who 
has not. You must do this one survey at a time. . To get to this screen click on the 
opinions icon on the first page of the study site. You will see something like screen shot 
1 below. You cannot bring up the surveys here because as you can see they are not "hot 
links". However you can see two hot links - blue or purple with underlines. The date 
and availability are also blue but I think that is just to make them easy to find. The "live" 
links are the ones with underlines. By clicking on a "submissions link" you will see a 
screen like the one captured in screen shot 2 below. The "detail link" is illustrated in 
screen shot 3. On the right you have some options (second set ) to help you find what 
you want without flipping through all the next and previous buttons. 



Screen Shot 1 First page of survey section 




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131 

Screen Shot 2 Submission option from previous screen shot. Note the blue highlighted 
next page button ~ that means there are more pages with lists. Once you go past page 1 
the previous page box will also be "live" - blue lighted, blue 




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Submissions: MBT! 

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Screen shot 3 Using the detail hot link you can see the participants actual responses. I 
sincerely request that you not do this for the participant's privacy and confidentiality. 
There is no way I can block this option in WEBCT so I am trusting each of you to respect 
the participant's privacy. 



132 



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Required Reading Study Protocol 

These articles must be read prior to beginning tow ork on this project so that we 

are all working from a common body of information. You may borrow the researcher's 

copies. All articles are available in the Educaiton Library, Library West, the Health 

Science Library, on the Internet, or are included (*) in your manual. You are also 

welcome to read the entire dissertation proposal but that is certainly not required or 

necessary. You may download the WebCT manual from http://www.webct.ufl.edu but 

this is not necessary and it contains a great deal of information you do not need. 

Colon, Y. (1994). ChatteiferMng through the fingertips: Doing group therapy 
Internet [web document]. Women and Performance Retrieved 2/15, 2001, from the World 
Wide Web: http://www.echonyc.com/~somen/Issuel7/public-colon.html. 



133 



*Meichenbaum, D. (1988). Cognitive-behavior modification workshop. Boston, 
MA: Harvard Medical School-Massachusetts General Hospital. 

Meichenbaum, D. (2000). Treatment of individuals with aneer-control problems 
and aggressive behaviors: A clinical handbook . Clearwater, FL: Institute Press. 

Murphy, L. J., & Mitchell, D. L. (1998). When writing helps to heal: E-mail as 
therapy. British Journal of Guidance & Counseling. 26 (\\ 21-32. 

*Rinaldi, A. H. (1998). The Net: User Guidelines and Netiquette Florida Atlantic 
University (web document). Retrieved 07/14 2001, from the World Wide Web: 
http://www.fau.edu/netiquette 

*Suler, J. (1997). Text-talk: Psychological dynamics of online synchronous 
conversations in text-driven chat environments. Rider University(web document). 
Retrieved 02/10 2001, from the World Wide Web: 
http://www.rider.edu/users/sule/pscyber/texttalk.html. 

♦Z'Boray, D. (1997). The Unofficial Smilev FAQ : author (web document). 
Retrieved 09/06 2001, from the World Wide Web: http://www.newbie.net 

Required Reading College Student Counseling 

Archer Jr., J. & Cooper, S. (1998). Counseling and mental health services on 
campus . San Francisco, Jossey-Bass Publishers. 

Cooper, S. & Archer Jr., J. (1999). Brief therapy in college counseling and mental 
health. Journal of American College Health. 48 (July). 21-28. 

Murphy, M. C. & Archer Jr., J. (1996) Stressors on the college campus: A 
comparison of 1985 and 1993. Journal of College Student Development. 37 (1), 20-28. 

Steenbarger, B. N. (1992). "Intentionalizing brief college student psychotherapy." 
Journal of College Student Psychotherapy. 7 (2), 476. 

Wilson, S. B. (1978). Cognitive intervention in the normal developmental 
problems of young adults. Journal of College Student Personnel. 29 (March). 136-140 



APPENDIX C 
COMPUTER-MEDIATED SESSION TRANSCRIPT 

This is a transcript of a computer-mediated session recorded by the WebCT 

system and downloaded to the researcher's computer. Only the researcher had the level 

of access required to see and download these logs. The only editing removed the 

participant's identification code and the facilitator's name. All spelling and grammar 

remains as produced. Samples of the facilitator's use of Internet counseling techniques 

emotion bracketing and textual visualization, described in Chapter 2, are highlighted in 

gray. Also noted in gray is the facilitator's explanation of the limits of confidentiality 

and the facilitator's amplification of the participant's use of the emoticon "lol". Lol is 

one of the most common emoticons used on the Internet but it is an acronym with 

multiple meanings - laughing out loud, lots of love, and lots of luck therefore it was 

important for the facilitator to find the precise meaning the participant intended. 

************************************************************************ 
***** 

New session has begun in EDU_DISS_Rooml. 

Time: Mon May 20 17:02:27 2002 
************************************************************************ 

***** 

*+**** —FACILITATOR entered EDU_DISS_Rooml. Time: Mon May 20 17:02:27 
2002 

FACILITATOR»This is Session one again for 

*+**** —PARTICIPANT entered EDU_DISS_Rooml. Time: Mon May 20 17:16:14 
2002 

PARTICIPANT»sorry I got lost 

FACILITATOR»Hello, I just wrote you an email! 

FACILITATOR» 

134 



135 



FACILITATOR»Was it hard to get in? 

PARTICIPANT»yes. . well I did not click on the dissertation link 

PARTTCIPANT»at first 

FACILITATOR»oh, no, that can get real messy 

FACILITATOR»Everything works fine until it doesn't |«fy|giiiil|) 

PARTICI PANT»lol 

FACILITATOR»How are you doing? 

PARTICIPANT»fine 

PARTICI PANT»and u? 

FACILITATOR»good. I have had a crazy morning, I work part time in 
Shands psychiatry, and I showed up for 2:30 for the group, but it was at 
1:00! 

FACILITATOR»So I missed it all {*&$*) ! 

PARTICIPANT»Sorry to hear that... I hate those kind of days 

FACILITATOR»yeah 

FACILITATOR»what about yours? Did you have class today? 

PARTICI PANT»yes, I enjoy my classes they are pretty easy going right 
now 

FACILITATOR»have you taken any Internet? 

PARTICI PANT»never 

FACILITATOR»so you are fresh! (gleefully wringing h&tofe) What we 
could do to you! 

FACILITATOR» (| 

PARTICIPANT»lol 

FACILITATOR»So, I want to explain a little bit about what this is 
going to be like. Is that cool? 

PARTICIPANT»yes 

FACILITATOR»I will spend about 5-10 minutes explaining a couple 
things, then we can talk about the "meat", and then in the end we will 
try to come up with a "plan" or homework for you to do until the next 
time I see you 

PARTICIPANT»okay 



136 



FACILITATOR»The next two sessions will be pretty much the same, 
except hopefully {smile) I won't have to spend that time in the 
beginning explaining 

PARTICIPANT»okay 

FACILITATOR»About halfway through the third session, we will finish 
up and then I will guide you to the guizes that you take at the end, 
there are 4 . 

FACILITATOR»Any questions so far? 

PARTICIPANT»nope :-) 

FACILITATOR»Ok, then . . . 

FAClLITATOR»the first thing I want to talk to you abo^^p 
lfidentiality. Basically, what is said (actually, written) 
ifidential, except that. Martye(the one who's doing this for he 

I||i|||li|i£?i f: ; wl;i||li ve: y: acce:li: llllll 

FACILITATOR»but . . there are some exceptions to that confidentiality 



PARTICIPANT»what are they 

FACILITAT0R>>1||||1||:|£^ 

" ^Iper authorities. But, don't worry, I would never do that without 
talking to yiegt^^ut it first 

FACILITATOR»Other than that, what is said here, stays here. Make 
sense so far? 

PARTICIPANT»yes 

FACILITATOR»cool <SJ»i3if 

FACILITATOR»the only other thing I wanted to say a little about is . 



FACILITATOR»that counseling is a little different than other 
relationships inasmuch as it is all about you 

PARTICIPANT»ok 

FACILITATOR»you are free to ask me questions if you want, even if it 
is personal, but I will always hestitate to answer to make sure that the 
conversation doesn't change to focus on me, cuase that's not the point 

PARTICIPANT»ok 

FACILITATOR»and that also, you are really doing the counseling, all 
day everyday, and the sessions themselves are more like checkups or 
coaching sessions 



137 

FACILITATOR»ok, whew! After all that, any q's? 

PARTICIPANT»ok 

PARTICIPANT»no 

FACILITATOR»then . . 

FACILITATOR»tell me what we are here to tak about 

FACILITATOR»talk 11111111 

PARTICIPANT»what area are you mostly concerned 

FACILITATOR»what do you mean? What area am I mostly concerned with? 
let me turn the question around — what area are you mostly concerned 
with? 

PARTICIPANT»personal relationship 

PARTICIPANT»relationships 

FACILITATOR»with a friend? boyfriend? tell me more 

FACILITAT0R>> (iiy»; : :.biHlii^ 



PARTICIPANT»boyfriend, I have this fear of commitment and I know 
where it came from but I just don't know how to get rid of it. I always 
question behind a guys motives for telling me his feelings even if we 
are dating (like movie and dinner) 

FACILITATOR»are you dating someone now? 

PARTICIPANT»several 

PARTICIPANT»I am scared to limit myself to one person 

FACILITATOR>>§||||§| ! 

PARTICIPANT»lol 

FACILITATOR»oh, I see, so you think that's why you are dating several 
at a time 

PARTICIPANT»yes 

FACILITATOR»how many are we talking here? 

PARTICIPANT»three 

PARTICIPANT»they are nice guys\ 

FACILITATOR>>so, you are dating three guys because you are afraid to 
limit yourself to just one. Before we go farther, let me ask — do you 
like all of them? 



138 



PARTICIPANT»good question lol 

FACILITATOR»that symbol 101; what does you mean: by it right there? 

PARTICIPANT»one is an ex, one likes me a heck of a lot more than I 
like him, and the other I could see myself with if I could get pass this 
"situation" 

FACILITAT0R»I see 

PARTICIPANT»laughing out loud 

FACILITATOR»ok, good 

FACILITAT0R»I wasn't sure 

FACILITATOR»ok, so one is an ex, but now are you still kinda dating 
him? 

FACILITAT0R»or is it totally over? 

PARTI CI PANT»no 

PARTICIPANT»he caused this fear 

FACILITATOR>>#G©|k. So right now you are only dating two 

PARTI CI PANT»yeah. . . I guess so 

FACILITATOR»wait, wait, wait (now I am the one laughing out loud*} 
what do you mean I guess so? 

PARTICIPANT»Well, the ex is.... I don't want him back. I keep him 
around for comfort 

PARTICIPANT»do you get what I mean 

FACILITAT0R»I am getting the idea — but not total just quite yet . . 

FACILITATOR»you still mess around with him? or . . you still call 
him on the phone . . or? (inquisitive look on my face) 

PARTICIPANT»straight to the point we mess around when I say 

so... comfort! You get me now? 

FACILITATOR»got it 

FACILITATOR»ok, and the other one, he likes you a lot more than you 

like him 

FACILITATOR»and then the third . . .ok, we got it. 

PARTICIPANT»:-) 

FACILITATOR»so, you said that your ex made you this way, and that you 
think you know why. tell me what happened 



139 

PARTICIPANT»well 

PARTI CI PANT»we were together for a year and a half 

PARTICIPANT»and I told him eight months into the relationship that I 
loved him 

FACILITATOR»and you meant it, or you just told him? 

PARTICIPANT»I meant it... he waited longer to say the same becuz he 
said that he did not take that word lightly 

PARTICIPANT»i meant it 

FACILITATOR»and, I am guessing something happened, right? 

PARTICI PANT»yes 

PARTICIPANT»we started going through problems, he was taker and I was 
always the giver. 

FACILITATOR»did he ever return the words? 

PARTICIPANT»I felt like he did not appreciate me. yes, he said he 
loved me 

FACILITATOR»and when it broke off, who broke it off, you? I am 
guessing, if you still keep him around? 

PARTICI PANT»After about three months of going through arguements off 
and on 

PARTICIPANT»I did broke it off because he told me one night during a 
conversation that he did not love me nor did he know if he meant it the 
first time. We were just having a conversation 

FACILITATOR»oh man 

PARTICIPANT»break it off 

FACILITATOR»it hurt really bad, right? 

PARTICIPANT»something in me change from that night. I never cried so 
hard in my life. 

PARTICI PANT»it still hurts 

FACILITATOR»yeah 

PARTICIPANT»I don't want that feeling ever again. 

FACILITATOR»did you all break it off then, or did you kinda hang on 
for a while? 

PARTICIPANT»I returned the favor 

FACILITATOR»you mean you told him the same thing? 



140 



PARTICIPANT»revenge is sweetest when he feels what he dished out 

FACILITATOR»or you acted in a way to make him feel bad 

FACILITATOR»like cheating on him, , etc. 

PARTICIPANT»I told him that we would just separate for a "minute." I 
kept him around like we were still "together." 

FACILITATOR»got it 

PARTICIPANT»I told him that I was going to date other people 

FACILITATOR»and that was how long ago? 

PARTI CI PANT»I did 

PARTICIPANT»spring 2001 

PARTICIPANT»about feb late jan 

FACILITATOR»did it feel better when you hurt him? or about the same? 

PARTICIPANT»liberating 

PARTICIPANT»i still cared for him but he needed to know that he could 
lose me 

FACILITATOR»but now . . although it was liberating in the moment, you 
are not liberated now, in fact, trapped 

FACILITATOR»right? 

PARTICI PANT»well 

FACILITATOR»cause you said you need to get over your "problem" . Or 
did I misunderstand? 

PARTICIPANT»liberating in the sense that I realized that I had the 
power to hurt him take the situation into my hands 

PARTICI PANT»bef ore I was the one crying 

PARTICI PANT»you are correct 

FACILITATOR»the question is now do you want to get back with him? 

would he? would you? or you think you need to just sort out and move 
through your feelings, but move on? 

FACILITATOR»we probably won't be able to make your world "perfect", 
but if you had a magic wand - - -how would it be? 

PARTICI PANT»no. yes. not right now. correct 



141 



PARTICIPANT»I would change his outer appearance and give him another 
chance. I have changed over the year and my prefences are very much 
different now. Appearance wise. 

FACILITATOR»how would you see things right now but in your perfect 
world? 

FACILITATOR»ok, ignore my last comment! {&rcULe} 

FACILITATOR»but, what about his inner, are you still in love with 
that? 

PARTI CI PANT»Fred would be taller, slimmer, no drama attached. I love 
him, but not in love. 

FACILITATOR»got it 

FACILITATOR»ok, so let me tell you . . .we are going to try something 
called REBT. Basically, it is a way of analyzing you actions 

PARTICIPANT»ok 

* 
FACILITATOR»I 'm going to try to explain a little bit about it, and 

then give you as "homework" something to use it on 

PARTICIPANT»ok 

FACILITATOR»Basically, when we have an event and then a reaction, we 
often have a thought in the middle of it that influences our reaction. 
But, often, we aren't aware of the thoughts 

FACILITATOR»so, we react "without thinking". 

FACILITATOR»for example, I come home from school, the dishes are 
still in the sink, and my husband is there and has been home all day 

PARTI CI PANT»you yell 

FACILITATOR»I get mad, because the dishes aren't clean 

FACILITATOR» right 

FACILITATOR»but the underlying thought there that made me angry was 
that he was lazy, and could have or should have cleaned up the dishes 

PARTICIPANT»ok 

FACILITATOR»now, that thought can or cannot be correct, but if I 
change my thought process, I might not get mad 

PARTICIPANT»ok 

FACILITATOR»for example, if instead I think, "well, he must have been 
doing something very stressful in order not to be able to clean up the 
dishes", then how might I react? 

PARTICIPANT»calm 



142 



FACILITATOR»you got it. 

FACILITATOR»so, what we can do is this. Maybe we might need to sort 
through your thoughts and feelings a little more next session, but you 
said that at least right now you just want to work through your feelings 
and get over them 

FACILITATOR»right? 

PART I C I PANT » ye s 

FACILITATOR»so, what I was explaining is with REBT what we try to do 
is figure out our underlying thoughts that might be getting in the way 

PARTICIPANT»ok 

FACILITATOR»so, how do you think we might apply that to your 
situation with Fred and/or the other guys? 

FACILITATOR»got any ideas? 

PARTICIPANT»fear of commitment has an underlying thought of "I will 
be deceived"? 

FACILITATOR»good. But even more so, "I will be deceived every time?" 
really good 

PARTICIPANT»i see 

FACILITATOR»ok (misprint, I meant no questionmark ) smile 

PARTI CI PANT»:-) 

FACILITATOR»so, since this is coming to a close, what do you think we 
could have you do for this week until next session? 

PARTICIPANT»I don't know 

PARTICIPANT»talk to the guy that I could see myself with? Confront 
old boyfriend? 

FACILITATOR»Those could be ideas, but probably right now you need to 
confront yourself more than others. cause for example you said that you 
might like the guy if YOU could get over this. but that might come at a 
later stage 

PARTICIPANT»ok 

FACILITATOR>>how about you make a list of three things that Fred did, 
and how you reacted. And then try to apply what we were talking about, 
about the underlying thoughts, and how you carry them over. 

FACILITATOR» 

FACILITATOR»Does that make any sense at all? 



143 



PARTICIPANT»yes 

FACILITATOR»good. so, it is about that time that we should go, any 
questions before we end? I will see you next week at this time 

FACILITATOR»that was a question (sraxle?) 

FACILITATOR»oops againl 

FACI LITATOR»he he 

PARTI CI PANT»yes 

PARTICIPANT»lol 

PARTI CI PANT»:-) 

PARTI CI PANT»I enjoyed myself 

FACILITATOR»good, so did I ! 

FACILITATOR»See you next week! 

PARTICIPANT»i never really talk about myself 

PARTICIPANT»bye 
*_**** — FACILITATOR left EDU_DISS_Rooml . Time: Mon May 20 18:21:54 2002 
*_**** — PARTICIPANT left EDU_DISS_Rooml . Time: Mon May 20 18:22:00 2002 

************************************************************************ 
****** 

Session in EDU_DISS_Rooml ended (all PARTICIPANTS have left) . 

Time: Mon May 20 18:22:00 2002 

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****** 



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BIOGRAPHICAL SKETCH 
Martha Lana Bogardus Groble was born near Meadville, Pennsylvania on 
September 4, 1947. She graduated from Cochranton Area Junior Senior High School in 
May 1965 and attended Indiana University of Pennsylvania where in January 1969 she 
earned a bachelor's degree with honors in Education (majoring in mathematics). She 
taught 7 th and 8 th grade mathematics at Roosevelt Jr. High School, Altoona, Pennsylvania 
before enrolling in the University of Oklahoma where she earned a master's degree in 
Anthropology in 1971 . She conducted or participated in academic fieldwork in southeast 
Alaska; the Yucatan peninsula; San Jose, California; and Sierra Leone, West Africa. She 
worked in education, collections, and exhibits at the Stovall Museum of Science and 
History; the Jacksonville Museum of Science and History; the Riley County, Kansas 
Historical Society; and the Kansas State University Planetarium. During her time in 
Kansas, she taught physics and anthropology at Kansas State University. After a 
parenting hiatus of several years, during that she was active in school, community and 
volunteer service, she established and worked in a psychiatric practice in 1983. In 1986, 
she enrolled in the University of North Florida and earned a master's degree in 
counseling psychology in 1989. She earned her license in mental health counseling in 
1992 and continued to work in the psychiatric practice. In 1993, she was awarded a 
Veteran's Administration contract for vocational rehabilitation counseling. To enhance 
her ability to provide excellent services to her veteran clients, she enrolled in the 
University of Florida, College of Education, Department of Counselor Education to earn 

160 



161 

a PhD. in mental health counseling (specializing in vocational rehabilitation counseling) 
in the fall of 2002. She is a certified rehabilitation counselor and a certified career 
assessment associate. She is an adjunct instructor at the University of North Florida in 
the department of Rehabilitation Counseling and she is the primary care giver for her 
husband's neptuagenarian parents who live with them. 

As a mathematics major, Dr. Bogardus began learning computer programming in 
1967. Her knowledge and skills grew as the computer world became accessible to 
individuals. She designed the computer lab at St. Mark's Episcopal Day School in 1993 
and focused her graduate research in the area of computers and counseling. 

She is an avid genealogist, proficient in the use of computer data bases to research 
lineages. She records her findings in traditional scholarly format and in personal 
photographic journals that she shares over the Internet in prominent genealogy sites, and 
on her family website. She enjoys textiles including sewing and quilting with a 
computerized sewing machine, and hand stitching needlepoint, petit point, crewel, and 
embroidery. She relaxes by reading fantasy literature (brain candy) and enjoys fantasy 
role playing gaming. When away from her computers, books and 30-sided dice, she 
hikes, swims, canoes, rafts, sails, and backpacks on four continents with plans to explore 
two more continents. Although she and her family camp extensively and world wide as a 
family or with Scouts and friends, her favorite campsite has always been Holiday Inn 
poolside. 



I certify that I have read this study and that in my opinion it conforms to acceptable 
standards of scholarly presentation and is fully adequate, in scope and quality, as a 
dissertation for the degree of Doctor of Philosophy. 






James Archer Jr., Chair 
Professor of Counselor Educati 



I certify that I have read this study and that in my opinion it conforms to acceptable 
standards of scholarly presentation and is fully adequate, in scope and quality, as a 
dissertation for the degree of Doctor of Philosophy. 





^y-^ 



M. Harry Daniel 

Professor of Counselor Education 



I certify that I have read this study and that in my opinion it conforms to acceptable 
standards of scholarly presentation and is fully adequate, in scope and quality, as a 
dissertation for the degree of Doctor of Philosophy. 



Lindas*.. Shaw 

Professor of Rehabilitation Counseling 



I certify that I have read this study and that in my opinion it conforms to acceptable 
standards of scholarly presentation and is fully adequate, in scope and quality, as a 
dissertation for the degree of Doctor of Philosophy. 




M. David Miller 

Professor of Educational Psychology 



This dissertation was submitted to the Graduate Faculty of the College of Education 
and to the Graduate School and was accepted as partial fulfillment of the requirements for 
the degree of Doctor of Philosophy. 

December 2002 




M. Harry Dank 

Chairman, Counselor Education 



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DeanJ College of Education 



Dean, Graduate School 




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UNIVERSITY OF FLORIDA 



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